Health Plan of Nevada drops five drugs from its coverage

Bob Shemeligian

Wednesday, May 6, 1998 | 9:12 a.m.

If you are among the nearly 150,000 area residents who are members of Health Plan of Nevada, you might be surprised to learn that the decision on what medications to prescribe for you -- at least in some cases -- is no longer being made by your physician.

HPN has joined a growing number of health maintenance organizations throughout the nation that have developed "formularies," or lists of drugs covered by those organizations.

Recently members of HPN were informed that five drugs are no longer covered by the HMO, which is owned by Las Vegas-based Sierra Health Services.

The medications are: anti-depressants Prozac and Zoloft, allergy medication Claritan, bronchial medication Proventil and heart drug Zestril.

Sierra spokeswoman Ria Carlson said HPN plans to issue a complete formulary June 1, and drugs that are not on that list will not be covered by the health maintenance organization.

Sierra spokeswoman Ria Carlson said the health maintenance organization has resisted this change for as long as it could, but the rising costs of pharmaceuticals have left the company with little choice.

"All our major competitors already have formularies," Carlson said. "You should remember that even standard Medicare doesn't cover outpatient prescription drugs and this is why the Medicare supplement industry is booming."

Carlson stressed that many drugs that will be on the June 1 formulary will be chosen based on effectiveness rather than cost, and those patients who wish to receive medications that are not on the formulary because of cost simply will be charged the difference between the cost of the drug on the formulary and the cost of the patient's drug of choice.

But Dr. Frank Nemec, chief of staff at Columbia Sunrise Hospital, said it has been his experience with other such plans that drugs not on the formulary are simply not reimbursed.

"In theory, it's a good idea to choose the least expensive drug that helps the patient, but the reality is that for those patients who are already taking another drug, it becomes onerous to make such a switch," Nemec said.

The physician explained that each drug has a different side effect and different dosage requirements, and to change from one drug to another "means you're just taking a chance."

Nemec explained that the recent edict by HPN is one of many changes brought about because of the attempts by lawmakers and health professionals to reduce the cost of health care in America.

"It's a reasonable thing to try to save money when the subject is health care costs," Nemec said. "But we need to ensure that we always have the physician's input -- especially in the prescription of medications -- and that the impact to the patient is fully appreciated."