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Friday, July 19, 2024

‘This is NOT OK.’ New UC pharmacy benefit manager leaves some employees without coverage of insulin, other medications

Professor Jonathan Eisen takes to Twitter to share how some medications are not covered by the new pharmacy benefit manager for UC PPO plans

By MARGO ROSENBAUM — campus@theaggie.org

This is the first installation of The California Aggie’s two-part series on the struggles of students, faculty and staff in receiving coverage for some medications and medical equipment by UC health insurance plans.

In early March, UC Davis professor Jonathan Eisen received a letter in the mail that his UC preferred provider organization (PPO) insurance plan no longer covered his preferred types of insulin as of Jan. 1. The clinical transition letter was dated Feb. 14, yet he received it after March 1. 

Eisen, who was diagnosed with type 1 diabetes at age 15, said his insurance had always covered his insulin throughout his 17 years as a professor at UC Davis, eight years at the Institute for Genomic Research in Maryland, seven years in his Ph.D. program at Stanford University and four years of undergraduate studies at Harvard.

Eisen, who is a professor with appointments in the UC Davis Department of Evolution and Ecology, the Genome Center and the Department of Medical Microbiology and Immunology, took to Twitter to share the news with his over 65,000 followers. “This is NOT OK,” read his tweet on March 7.

“I was frustrated and kind of pissed off, and also felt like this triangulated a lot of things that I’d heard a lot of people talking about, which [were] problems with pharmacy benefits and insulin coverage,” he said in an interview with The Aggie.

On Jan. 1, Navitus Health Solutions took over the administration of prescription drug benefits for UC employees and retirees on Anthem Blue Cross PPO insurance plans: UC Health Savings Plan, UC Care and CORE. The prescription benefits for these plans were formerly managed by Anthem IngenioRx. Pharmacy benefit managers, such as Navitus, manage prescription drug benefits and costs for health insurers, large employers and other institutions. 

“Every prescription benefit manager (PBM) uses its own formulary, which is a list of drugs that are covered by the plan,” a UC advisory sent in January reads. “While the Anthem IngenioRx and Navitus formularies are similar, there are differences, which could affect your individual medication costs.”

Approximately 15% of UC Davis employees are on Anthem Blue Cross plans and, therefore, were impacted by this change to Navitus, according to UC Davis Health Care Facilitator Guerren Solbach.

For over 10 years, Eisen has been using Novolog and Lantus brands of insulin. According to the UC formulary and UC benefit plan website, the new pharmacy provider covers other brands of insulin, like Humalog, but not the two brands Eisen previously used and prefers.

Although Eisen said he was given a grace period until March 31 to acquire Novolog and Lantus at the price he paid under the former plan, he would have preferred to have received notice of this before the beginning of the month. “This is NOT OK either,” Eisen’s follow-up tweet read

When Eisen initially learned about the changes to UC insurance benefits, he did not imagine the changes to be this significant, he said. Insurance provider shifts happen frequently, and while it is “annoying and painful,” they do not usually result in large differences in coverage.

Yet, that was not the case this year as the pharmacy benefits are now decoupled from healthcare benefits. Previously, Anthem Blue Cross provided both pharmacy and healthcare benefits, but now Navitus provides pharmacy benefits for Anthem Blue Cross PPO healthcare plans.

“It’s confusing; it’s slow; it’s cumbersome,” Eisen said. “Now your information is in multiple places, and it’s lame. There’s no other way to put it.”


Eisen’s diagnosis

In 1984, Eisen was experiencing the classic signs of diabetes — he regularly experienced fatigue, had to go to the bathroom frequently and felt sick for months. At the time, Eisen was a pitcher for his baseball team and in between each inning, he had to run down a hill to the bathroom. Eisen detailed his diagnosis in a TED Talk in 2012.

“​​I was literally peeing out all the sugar that was accumulating in my body,” he said.

After pitching a good game, he went on his first-ever backpacking trip in Old Rag Mountain in West Virginia with an Eagle Scout friend and his brother. He drank their supply of water that was meant to last for two days in about 15 minutes and submerged his face in puddles to drink extra water like a dog, he said. 

“I was dying; I was literally dying,” Eisen said.

Eisen said he “somehow” survived the backpacking trip and started telling his father, an endocrinologist for the National Institutes of Health (NIH), about how he was feeling. 

After not being able to stand at a party for his father’s NIH lab, “something clicked” in his father’s head, Eisen said. They left the party and bought a urine sugar testing kit. Eisen’s blood sugar levels were off the charts — Eisen’s father instantly knew he had diabetes and brought him to the emergency room.

“​​I was very, very, very sick,” Eisen said. 

Eisen’s weight had dropped from 170 to 120 pounds and he was experiencing “full-blown” diabetic ketoacidosis, which is a serious, life-threatening complication of diabetes where the body does not have enough insulin for blood sugar to enter cells to be used as energy, according to the Centers for Disease Control’s definition. 

“My body was basically digesting itself,” he said. “They immediately diagnosed me as a diabetic — it took like five minutes […] My body was suddenly for the first time in five months starting to work.”

Since Eisen has type 1 diabetes, his pancreas makes little to no insulin — a necessary hormone that regulates metabolism and blood-sugar levels. People receiving treatment for type 1 diabetes inject synthetic insulin or use an insulin pump to manage their blood-sugar levels and prevent damage to their heart, kidneys and other organs.

Thirty-eight years later, Eisen has been on 10 to 15 different types of insulin and has finally perfected a regime that functions well for him. After finding the medications and doses that worked for him, Eisen said he did not want to change his insulin as a result of the change to Navitus as the UC PPO plan’s pharmacy benefit manager.

“So you just don’t want to switch when you have something that’s working,” Eisen said. “Insulin regimens are very complicated and you develop them [and] fine-tune exactly how you’re getting yourself insulin for decades with all sorts of feedback that you learn and with your medical team.”

Dr. Polly Teng, an assistant professor in the Division of Endocrinology at the UC Davis Medical Center, said patients should talk to their diabetes provider or endocrinologist before making changes to their insulin types or intake. It is possible, however, to switch brands of insulin as long as they are within the same category of fast-acting or long-acting insulins. 

“We do have different types of insulin that have a different duration of action — differences in how quickly the medication works,” Teng said. “So generally, if we’re switching someone with diabetes from one insulin to another, we want to make sure that we’re still switching them to the same category type of insulin.” 

The insulin doses given are the same regardless of the insulin formulation, she said, which makes it easy to do a “one-to-one switch from one insulin to another insulin.” 

“The general concept [is] that patients should not expect a difference in the insulin dosages with the switch, and they should also most likely not see any significant differences and how their glucose responses,” she said. 

Graphic by Kellie Lu / The Aggie

Complications with applying for an exemption

It was initially unclear to Eisen which insulin would be covered by the new pharmacy benefit manager for his UC Health Savings Plan. 

Navitus, which is partly owned by Costco, uses Costco Pharmacy for mail-order prescriptions. In January, Eisen attempted to transfer his prescriptions to Costco and was told in February that his preferred insulin Novolog would not be covered, but a generic version of it would be. His doctor wrote a new prescription for the generic version of Novolog, but after the clinical transition letter from Navitus was sent in March, Eisen said he learned this generic insulin would not be covered either.

After waiting on the Navitus call line, he learned he would either have to switch to different insulins, such as Humalog, or apply for an exemption. ​Since Navitus sent the initial clinical transition letter so close to the deadline, Eisen was left with very little time to decide. 

“It’s just awful,” he said. “A letter I received on March 1 seems like it was written in December because it’s talking about things in the future that are going to change. And they’re giving you a heads up that they’re not going to cover my insulin anymore in January, but now it’s March.” 

After reading scientific literature and guides from diabetes organizations, Eisen said he found that Novolog and Humalog are not exactly equivalent. 

“If I switch to the Humalog I’m going to have to completely change my insulin delivery system with my pump and learn how to do it, and I’ll probably be under worse control for a while,” Eisen said. “This is horribly stressful.” 

According to the new policy, exemptions for medication coverage can be made “with prior authorization and “for medical necessity. “In this case, the member pays coinsurance on the cost of the brand-name drug, or (for UC Care members) the Tier 3 (non-preferred) copay,” the policy states. 

Eisen said he was unwilling to switch insulin and decided to apply for an exemption. Eisen could be paying “something like $8,000 [or] $10,000 a year,” out of pocket for insulin without an approved exemption, but it is possible that some of those funds would be covered by his insurance if he went over his deductible, he said. 

Insulin prices in the U.S. have tripled in the past decade, and on average, the medical costs related to diabetes in the U.S. can reach over $9,500 per year

“If I buy insulin at the regular cost, it’s literally going to be thousands and thousands of dollars for the year,” Eisen said. “Insulin, even though it shouldn’t be, is insanely high priced. I mean, just completely ridiculous prices.”

Furthermore, Eisen said he and his doctor had to wait on the phone to initiate the exemption request. While Eisen’s doctor was able to get through to Navitus, Eisen said he was on hold “forever” and eventually hung up.

While Eisen was originally “not confident” that his exemption would be approved, he received a message that Navitus will cover his preferred insulin, Novolog. 

“Well — good news for me — I have been told that Navitus has been instructed to cover the insulin I have been using,” he tweeted on March 23.

The request for Lantus was initially rejected by Navitus, Eisen said. But on March 28, he received a call from Navitus that they would also cover Lantus insulin.

“I got a call today saying that my Novolog and Lantus insulin would indeed be covered by Navitus,” he tweeted on March 28. “Yay. I am very happy. Now I want to know what is going to happen to others who were harmed by the new plan …”

Teng, the endocrinology professor, said that her patients with diabetes have not experienced many issues with getting their insulin covered since the switch to Navitus. Two of her patients, however, are encountering challenges with coverage of GLP-1 agonists: medications that increase pancreatic insulin production and insulin sensitivity, improve cardiovascular outcomes and have weight loss benefits.

“Navitus has put a lot of roadblocks for us to continue these patients on these higher doses of medication,” Teng said.


Support from the community on Twitter

On Eisen’s Twitter thread, many UC employees have responded saying they have also experienced challenges contacting Navitus or with getting exemptions approved for their medications. Eisen said that some UC employees and their families experienced other medications beyond insulin not being covered.

“Many people are experiencing similar things at UCs and other institutions and are equally frustrated or more so,” he said.

Eisen said he received over 100 direct messages with advice and was offered free insulin by some people on Twitter. He said he has never gotten that many messages about any of his tweets. 

“Clearly, this hit a nerve, and a huge number of people, first of all, couldn’t believe that this is happening and other people are like, ‘Yeah, I can believe it because it happened to me this year and last year,’” he said. “So I got lots of support.”

Seth Sanders, a professor of religious studies in the Jewish Studies Program at UC Davis, tweeted about what he had heard from colleagues and friends affiliated with the UC. With the clinical transition letter being sent so late, “you really couldn’t ask for a more terrorizing type of announcement,” he said in an interview.

Elena Fuchs, an associate professor at UC Davis, tweeted on Eisen’s thread about also being impacted by the switch to Navitus.

“This is us too,” Fuchs tweeted on March 23 on the thread. “They are suggesting a switch to a medication that will NOT work for us but according to them it’s the same thing.”

Crystal Kolden, an assistant professor at UC Merced, responded to Eisen’s tweet stating that Kolden’s son had also been impacted by the switch to Navitus.

“We received the same letter template saying they won’t cover my son’s albuterol inhaler,” Kolden tweeted. “Whoever switched to Navitus at the UCOP chose poorly.”

The time and effort Eisen and his doctor spent applying for an exemption paid off for Eisen since his exception was approved by Navitus, but he said he is unsure whether others have had luck getting their medications covered.

“Also – would like to know if this is going to be done for other diabetics […] will try to find that out too,” he tweeted in the thread on March 23. “And also – what about other people who had their Rx meds changed to not being covered — would like to know what is going to happen there [too].”

The UC acknowledges and apologizes for complications from switch to Navitus 

The University of California Office of the President (UCOP) Strategic Communications and Media Relations declined an interview on March 24 with The Aggie, but Associate Director of Media Relations for UCOP Ryan King said via email that the UC has been working closely with Navitus to resolve any issues employees are facing and forwarded The Aggie a letter sent to members of UC medical plans with pharmacy benefits administered by Navitus on March 21. 

Signed by Vice President of Systemwide Human Resources Cheryl Lloyd and Executive Vice President of UC Health Dr. Carrie Byington, the letter informed impacted community members how Navitus and the UC are addressing these problems. The letter states that it was sent “to acknowledge — and apologize for — the problems many members of the UC community are experiencing with Navitus Health.”

Last year, UC Health and UC Systemwide Human Resources selected Navitus to administer pharmacy benefits starting in 2022, because it provided the UC with the “best overall flexibility, service, and affordability,” the letter states. 

The decision was made after a committee made up of UC Health, Systemwide HR, UC faculty with pharmacy expertise and UC’s retiree association conducted “an extensive formal bid process,” according to the letter. 

The UC acknowledges that the change has resulted in some members experiencing changes in their prescription drugs, “time-consuming authorization processes” and denials by Navitus, causing “unnecessary anxiety and frustration.” The letter states that the UC has “heard from too many members who have been negatively impacted by this change.”

The letter states that Navitus failed to meet the scheduled target date for mailing a clinical transition letter, which could explain why Eisen did not receive his notification until early March. The UC’s letter stated that this caused “hardship and worry for faculty, staff, retirees and their family members.”

Navitus has faced challenges with customer service staffing, explaining the customer service call waiting times “that far exceed Navitus’ standards and UC performance guarantees,” according to the letter. To combat these delays, Navitus has signed onto a number of customer service improvements.

As a result of the delay in mailing clinical transition letters, Navitus has initiated a number of measures to help members with the transition in medications and has provided an extended transition period, for drugs that are not covered, to the end of April, beyond the extension to the end of March that was initially promised. 

UC Health, Alliant (a UC consultant) and Navitus will audit and review the protocols Navitus uses for denials to ensure they follow Navitus’ internal guidelines, industry standards and Medicare guidelines and to identify and correct any gaps, the letter states. 

“We take these problems — and our responsibility to ensure that members of UC health plans have access to the prescriptions they need — very seriously,” the letter states.

Beyond information in the UC’s letter, King said he could not provide any further information at the time as to why Navitus was selected as the new prescription benefits manager or how costs are changing for members with PPOs.

A Navitus spokesperson provided a statement to The Aggie on March 29 stating that the pharmacy benefit management company works “with customers to develop the best formulary for all their employees.” They said that “providing our customers and their members with access to quality, appropriate prescription drug coverage is Navitus’ top priority.”

According to the statement, Navitus cannot comment on individual employee coverage situations, but they “we are working closely with the University of California to address their concerns and ensure we are providing the highest level of customer service to their employees and access to the medications they need.” 

Eisen received the UCOP letter last week along with others impacted by the switch to Navitus, and he took to Twitter to share his grievances and lingering questions.

“Clearly, this touched a nerve and 100s of people shared stories of how they were also harmed by the new UC system as well as by other switches in pharmacy benefits in their systems,” he tweeted on March 22

While Eisen said he is glad that the UC is “doing something here” and acknowledged the challenges and frustrations people faced as a result of the switch to Navitus, he tweeted that “(1) the whole system really should be switched back to a better one w/ more coverage and (2) unclear how much impact these changes will have.”

With regard to the consultant brought in to monitor Navitus’ actions, Eisen tweeted that the funds could be used elsewhere — perhaps to cover more medications and medical equipment.

“I think some of this will help but it remains to be seen whether or not anything will improve,” he tweeted in the same thread. “There is still no commitment to actually cover drugs that Navitus says are not covered.”

Switch to Navitus is likely an effort to save money

Beyond what was stated in the UCOP’s letter, Eisen and other UC employees on PPO plans are left wondering why the UC changed its pharmacy benefit manager to Navitus. 

“The previous system worked very well in my opinion — it was not perfect, [but] no system is,” Eisen said. 

Health Care Facilitator for UC Davis Solbach was not involved in the decision-making process but said the switch to Navitus was to save money.

“It was to keep the Anthem premiums from going up,” he said. 

The Navitus website states that its “lowest-net-cost philosophy provides clinically sound, cost-effective alternatives, such as generics or less expensive brands, creating a high-performance formulary that consistently delivers the lowest net cost.”

After getting approved for his preferred insulin, Eisen still believes he should not have had to put in as much time and energy into advocating for his medications, he said.

“Mind you, none of this should ever have happened in the 1st place – this was just a poor set of decisions to switch to a company and a pharmacy benefits plan apparently designed to save money by forcing costs and pain onto UC employees,” Eisen said in a tweet on March 22.

Yet, Eisen acknowledged that the UC was trying to improve the situation.

“But at least they were trying to do something to back track the disaster,” he said in the same tweet thread.

Next steps for Eisen

In addition to sharing his frustrations with the UC insurance plans and Navitus, Eisen said he has gained a reputation for posting about his grievances with academia, such as critiquing the under-representation of women in conferences. 

“I have made a point to tell people that if you observe something that you think should be shared, but you don’t feel comfortable sharing it, I will,” he said. 

Eisen said that as white man with tenure and a full professor position at UC Davis, which he says is “an institution that is generally supportive” of his work, he acknowledges his privilege in academia, especially in comparison to younger faculty, or people from traditionally underrepresented groups.

“The risks for me for sharing this information are enormously less than the risks of a student, or a minority or a junior faculty member who doesn’t have tenure yet,” he said.

Because of his “position of perceived privilege,” Eisen felt comfortable sharing this information on Twitter, especially because he knew others were likely experiencing similar challenges.

“If you’re not going to use your privilege for something to help other people, what the f*** do you have it for?” Eisen said. 

After 17 years at UC Davis, Eisen said this experience may cause him to consider working elsewhere. Eisen acknowledges that the UC, and UC Davis specifically, is not perfect — most faculty have frustrations with certain aspects of their institution. While he said he likely would not take another position right now, this is the first time when he has understood why people take other jobs outside of the UC system. 

“I don’t think I’ve ever seen anything this pathetic,” Eisen said. “It’s embarrassing. Even though people recruit me for jobs every like three months to apply for things, I’ve never once even remotely considered it before. I’m going to consider it now because this is just a bad sign.” 

Written by: Margo Rosenbaum — campus@theaggie.org



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