Working With Formularies
J. Greene


Q: My HMO keeps changing my medications. I took one blood pressure drug that I liked, and they switched it to something else which did not work as well. The new drug also has special times when I can and can’t take it, and instructions for when I can eat. What right does the HMO have to tell me I can’t eat breakfast for at least an hour or I can’t snack at night for the rest of my life?

A: It sounds as if you’ve run afoul of your HMO’s “formulary,” or list of acceptable drugs. HMO's started playing around with their drug lists several years ago as a way to save money.

      As many health-plan members have found, however, it's not so easy to make blanket assumptions that one medication will work the same in all people. It's common that a given drug will cause side effects in one person and not in another, or may be more effective for some patients than others. That's why multiple drugs are made in given pharmaceutical "families," so your doctor can switch you around to the one that works best. This is common among people with high blood pressure or depression, for instance.
      The practice of using formularies has been rising rapidly; nearly 90 percent of HMOs now use such lists, according to an industry survey. It also found that 63 percent of HMOs require that a generic drug be substituted for a name-brand drug when the generic is available.
      Your HMO may have an open formulary, meaning that the plan will pay for prescription drugs that aren't on the list, but you might have to pay an extra copay or your doctor might be encouraged not to prescribe that drug. A closed formulary, in contrast, is more restrictive; a physician wishing to prescribe a drug not on the list must make a special request.
      Patients run into this problem in a number of situations. In your case, the HMO has changed its list of approved drugs for its current patients.
      If this happens to you, don't just accept it because the health plan says so. There's a decent chance you can get your medication of choice if you can make the case that it works better for you and if you can get your doctor to help you make the case. Unfortunately, you may end up having to do this after you've been switched to something that doesn't work as well, says Liz Helms, a steering committee member of Sacramento, Calif.-based consumer group Citizens for the Right to Know. "I know of a patient who was switched five times on blood pressure medication," Helms relates. "Finally her doctor said, 'This is ridiculous,' and requested that she get the original medication. And it wasn't even an expensive drug."
If this happens to you, try to get your doctor to write a letter to the HMO explaining why a non formulary drug is better for you.
      If you change doctors, make sure they know which medications you're on. If the doctor suggests a new one, ask why. Some doctors deal with so many different health plans they can't keep track of all the formularies, so they just stick with the most restrictive one. Make sure you understand any prescription changes, whether they're made by your physician or by your pharmacist. "People need to ask questions and not be afraid," Helms recommends.
      Also be aware that HMO plans can sometimes be slow to add newly introduced drugs to their formularies. If a new medication comes out for your illness, ask your doctor whether it would be appropriate for you.
      In a handful of states, state law makes challenging the formulary a little easier by guaranteeing HMO members the right to an unlisted drug if the formulary medication might do them harm. The states that have passed such laws, as of mid-1998, are Arkansas, California, Georgia, Indiana, Missouri, Ohio, Oregon and Vermont.
      This is an important issue to keep in mind when you're choosing a health plan, especially if you have a chronic illness such as high blood pressure or asthma that requires a regular medication. When you're making that choice, ask the health plan for the list of drugs, or whether your drug is on the preferred list. If there's a formulary, ask whether it's open or closed. Unfortunately, HMO's have a bad track record of disclosing that information, but in at least one state, legislators have made the task a little easier. A new state law guarantees California consumers access to HMO formularies. In fact, they're posted on the Web site of Citizens for the Right to Know.

HMO's Return                                  Our Rights Return
               HMO's Return                      Our Rights Return