California demands coverage for drugs with over-the-counter competitors

State regulatory guidelines would allow insurers to charge higher co-pays and could mean extra paperwork for physicians.

By Robert Kazel, amednews staff. April 28, 2003.

At least one state is telling insurers that access to prescription drugs is nothing to sneeze at.

The California Dept. of Managed Care, which regulates the state's HMOs, has sent an advisory notice to health plans stating they should not end coverage of a whole class of allergy drugs simply because one medication -- Claritin (loratadine) -- has gone over-the-counter.

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Region: West

Right now, this warning primarily applies to users of nonsedating antihistamines. The allergy drug Claritin went over-the-counter in December 2002, and under the guideline issued by the California agency, payers cannot automatically decline to reimburse patients for competing products such as Zyrtec (certirizine hydrochloride) and Allegra (fexofenadine hydrochloride).

The warning to payers was "a precautionary action" intended to prevent insurers from unfairly halting access to whole classes of drugs, in case they were considering it, and could influence other states because "California patient rights laws are a model for the nation," said Steve Fisher, deputy director of the state managed care department.

The advisory was spurred by some complaints to the agency's hot line from patients who were beginning to have trouble getting insurance coverage for the drugs they wanted.

The state's action is reassuring, said Jeffrey Kishiyama, MD, president of the California Society of Asthma, Allergy and Immunology. Dr. Kishiyama said doctors had been hearing "rumblings from insurance companies that they would limit all antihistamines" after Claritin became available on store shelves. He said allergists in the state had asked managed care regulators to look into the matter last fall.

Insurers can still require patients to try Claritin first before covering prescription allergy drugs.

"The idea that all these drugs are exactly the same was not a scientific or medical fact," Dr. Kishiyama said.

Insurers in California still are being allowed to charge patients higher co-payments for the prescription rivals of Claritin. The new guidance from the state also does not interfere with insurers' ability to require patients to try Claritin first before being covered for a prescription drug.

Because of stepped-up preauthorization rules, in California and elsewhere, doctors are facing a dust storm of paperwork associated with getting payers to cover Claritin's prescription rivals. Physicians are being asked to fill out forms, in addition to the prescription, verifying that the patient needs the prescription medicine and explaining why Claritin or a generic equivalent isn't being prescribed. Sometimes copies of past medical records also are being required.

"It creates a problem for the physician," said Theodore Kanellakes, MD, an allergist in Joliet, Ill. "The physicians must get the records, it ties up staff and a phone line. There's a hassle factor. It's all time-consuming, and it just becomes a source of irritation."

Even though the new California guideline is, strictly speaking, merely advisory, insurance company executives said they supported it and that they hadn't planned to drop coverage of entire classes of drugs. Robert Seidman, chief pharmacy officer of WellPoint Health Networks, said the guidance from California "complements all of our actions to date." WellPoint is continuing to tighten prior authorization requirements, though.

"The reason is not to make life difficult," said Michael Belman, MD, WellPoint staff vice president and medical director of quality management. The company's efforts to tighten reins on drug utilization is justified, he said, because employers could drop prescription drug coverage altogether due to soaring expenses.

Aetna Inc. also doesn't have objections to the California advisory because the company "doesn't have a one-size-fits-all approach" to drug coverage, said spokeswoman Betsy Sell. But, like WellPoint, Aetna has typically instituted increased co-pays, drug tiering and precertification requirements in the case of reimbursement for Claritin competitors, she said.