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Scrubbing In: Insurers' decisions on drugs mystify

My patient, a 59-year-old Cambodian woman, has amassed one of those thick charts, the size of a small coffee-table book. It means she's a veteran of our cornea clinic.

My patient, a 59-year-old Cambodian woman, has amassed one of those thick charts, the size of a small coffee-table book. It means she's a veteran of our cornea clinic.

At her most recent appointment, she looked unhappy. "My eyes burn and itch," she said through her son who translated. "I can't sleep at night."

Ever since her insurer decided not to cover Restasis, a drop for severe dry eyes, her symptoms had returned. The decision seemed odd since the drug had been approved several times before.

No one ever taught me this in medical school, but formularies - the insurer's preferred list of drugs - are often the final say when practicing medicine. You can study hard and read the current journals to know the latest options, but if an insurer doesn't cover it, you're out of luck.

A severe case of dry eye can be devastating. I've had patients apply for disability from their dryness. They have light sensitivity and burning to the point that they cannot work.

My patient has tried various concoctions of drops and ointments over the years.

She finally got some relief recently when we started Restasis, a topical anti-inflammatory drop.

So why would her insurer suddenly stop covering her drops, making her pay about $700 for a six-month supply? My attending doctor suggested that I re-petition. And so I did.

I filled out the sheet pretty much as my colleague had a few months before.

"Failed other therapies," I wrote. Then I added: "Since being off Restasis, can't sleep at night."

I faxed it off and kept my fingers crossed.

Meanwhile, to get a better shot at approval, I thought I should call the insurer. Of course I knew better.

Clinic was busy as usual.  Plus, I recalled an attempt I had made a few months earlier.

A patient who had a corneal transplant was tapering off his steroids. He had gone from a high-potency steroid many times a day to once a day and now was ready for an even less potent one.

But we had to keep him on the stronger one - which he didn't need - because his insurer would not cover the costlier low-dose steroid. We thought our argument was sound: Stronger steroids make cataracts and glaucoma more likely.

So I was angry when they denied our request for his "pre-authorization." I called the insurer and got lost in a phone maze a couple of times. Then, I kept pressing 0 and somehow got to a human being.  (This is why some doctors' offices hire teams of employees to deal only with insurance issues.)

"May I speak to the person making decisions about what to cover for ophthalmologic therapies?" I asked.

The operator told me that I needed to fill out a "pre-authorization" form.

"But surely, there must be someone I could explain this to over the phone," I said.

Back came what sounded like a robotic response. "A clinical pharmacist will get back to you within 48 hours by fax."

I often wonder who makes up these lists for what is and isn't covered.

Yes, I understand that the correct drug is important in a world with limited resources. And obviously pharmaceutical companies are trying to make a profit, taking advantage of the fact that in many cases they have a 17-year patent on the medicine and can charge whatever they want.

But some coverage decisions are puzzling.

Why pay for only one pair of glasses for children per year? Isn't it a certainty that they break them? Why do most patients have to pay cash for rigid contact lenses but insurance will cover corneal transplants?

Doesn't this skew the decision-making toward a riskier procedure?

And it's a mistake to think that existing public plans will solve this problem, as some suggest in the health debate.

This older patient's plan was actually a Medicaid plan run through a local HMO. It might be better to let patients pay a small percentage of the total and let them decide if they can swing the more expensive drug.

Meanwhile, perplexities abound. Why did the HMO approve a drop for several months, and then suddenly unapprove it?

I wonder if insurance and pharmacy execs are cutting secret deals so that a plan will have a financial reason to cover one drug over another.

Or maybe there's a technical advisory committee of highly trained scientists who weigh the pros and cons of each option, and then take into account the costs.

Or maybe it just depends on what kind of day the approver is having. I'll never know. The only thing we're allowed to do is fax them.

As for my patient with dry eyes, the fax finally arrived. "Your patient has been approved for Restasis for 6 months. Please inform them."

I celebrated the good news with her daughter, who would translate it for her. And now she's back in business - for six months at least.