Hawai'i's state and county workers are grumbling about changes in their drug insurance health plan that ask them to switch to generic or low-cost alternatives or potentially face paying hundreds of dollars more for their prescriptions.

About 87,000 workers, beneficiaries and non-Medicare participants in the state Employer-Union Health Benefits Trust Fund were informed of the changes earlier this summer as part of the EUTF's efforts to cope with skyrocketing health care costs.

But some employees aren't happy with the modifications to the drug plan, which include required use of a Florida mail-order pharmacy for regularly filled prescriptions. They say the EUTF is steering them to drugs their physicians didn't initially prescribe.

"It appears that health/medical treatment will be dictated by an insurance company and not by one's physician," said Randy Iwase, a former state senator and gubernatorial candidate.

"I've never gone to an insurance company to diagnose my medical condition — don't know if they have the expertise to do so, nor are they licensed to practice medicine in Hawai'i."

The EUTF modified a drug plan covering state and county workers last month with the goal of shaving millions of dollars of costs and keeping member premiums from surging. But some employees have turned a thumbs-down on the changes and say they'd rather pay the higher premiums.

Already, some workers and retirees who aren't covered by Medicare have protested the mandated use of a Florida pharmacy for so-called maintenance drugs, those taken on a continuing basis. As reported earlier, local pharmacists say the plan will send business out of state and may force them to lay off workers.

The other changes are also provoking an outburst of criticism.

Complaints are piling up as InformedRx, the pharmacy benefits manager contracted by the EUTF, sends out letters alerting people of pricing for preferred and nonpreferred drugs.

Kailua resident Barbara Volheim received a letter saying she should switch her Nexium prescription to Prilosec OTC, which would carry a copayment of $5 for a one-month supply and $10 for three months.

If she chooses to continue on Nexium, a nonpreferred medication, the estimated copay would be $300 to $315 for one month, and about $500 for a three-month supply of the 40 milligram pills from the InformedRx mail-order pharmacy, InformedMail.

Another state employee, Janice Higa, was informed she should switch from a number of brand-name drugs to generics. If she doesn't, she'll face an out-of-pocket copay of $520 a month.

"I've been very upset with what the state has put in force," Higa said.

Iwase said he was told he would face copays of up to $475 a month for two non-preferred drugs unless he switches to what is being recommended by InformedRX. He sent a letter to the EUTF asking which state law allows such pricing actions by insurance companies.

Currently, a grace period exists as a transition to the new plan takes place over the next several weeks.

LOWER PREMIUMS

EUTF administrator Jim Williams acknowledges the uproar, but noted that the plan's 10 trustees carefully considered many of the issues being raised. Given the economic circumstances, they chose the plan modifications to save employees and state and county employers money.

For example, the mandatory mail-order program for maintenance drugs is saving more than $10 million and keeping a premium increase down to 23.7 percent from the almost 30 percent it would have been.

The EUTF has said there's also an issue of fairness that came into play under the old system, with members on lower-cost drugs helping subsidize prescriptions of people with higher-cost medicine for the same ailments.

Moreover, Williams said, people don't have to make the switch to lower-cost medicine if they don't want to. They may face higher copayments, though.

"We do get people saying you're forcing us to change," Williams said. "Well, we're not."

Patients can have their doctors apply for authorization to continue on current drugs. If a panel of InformedRx's medical advisers decides there are valid reasons, the member will be allowed to stay on the prescription at a low copay.

But Williams said many people may want to switch to the generics.

"Study after study shows that generic is identical to the brand name," he said, acknowledging there may be instances where some patients have reactions to the generic pills and must stay on the brand-name drug.

'YOU HAVE A CHOICE'

Another part of the program calls for use of lower-cost alternatives in three categories of drugs — cholesterol-lowering statins, anti-heartburn/ulcer drugs known as proton pump inhibitors and allergy medications known as low or non-sedating antihistamines.

The EUTF, on the recommendation of InformedRx, has identified drugs that treat the same condition but cost less.

"Again you have a choice," Williams said. "If you choose to continue with the higher-cost drug, then you have to pay the difference."

Among the drugs included in this is Lipitor, which claims to be the world's No. 1 prescribed branded drug and is not available as a generic.

The EUTF's recommended drug in this category is simastatin, a generic of Zocor, another branded cholesterol drug.

Both drugs have been proven to lower cholesterol. Cardiologist Thomas Behrenbeck, responding to a question on the site MayoClinic.com, said Zocor is as effective as Lipitor when given at twice the dosage.

He noted that Zocor may not be as effective as Lipitor at higher dosages, since its maximum dose is 80 milligrams (the equivalent of 40 milligrams of Lipitor.)

Behrenbeck advised that each patient talk to their doctor and "keep in mind that each of these medications is different and you may tolerate one but not the other."

Williams said the changes are backed by studies showing the effectiveness of drugs on the preferred list.

"In most cases, people should be able to take the preferred drugs," he said.

SOME PRICES HIGHER

Higa said she was told that she may, in seeking to stay on a nonpreferred medication, have to try the generic to see if it's just as effective. That doesn't sit well with her.

"Why try me on something that may not work?" Higa said.

Volheim has similar questions about funneling people toward drugs that may produce reactions. She also discovered that copay prices for Nexium being offered by InformedRX's InformedMail pharmacy in Florida were higher than what she could get at her local Walgreen's.

Volheim said a letter from InformedRx quoted an estimated price that was about $100 more than what the local pharmacy said it would charge for a 30-day supply.

A check of Drugstore.com for a 90-day Nexium supply of 40 milligram pills was $472, a little less than the estimated $500 Volheim said InformedMail quoted her.

InformedRx's materials say the copay prices for non-preferred drugs are estimations and may vary depending on market fluctuations. When asked, the EUTF's Williams said he wasn't previously aware of the situation and checked with InformedRX on the pricing discrepancy.

"That was a valid concern," Williams said. He said a recommendation will be made to EUTF trustees that the policy be amended to allow people on maintenance drugs who don't want the preferred drugs or generics to shop where they want and not be required to use the Florida pharmacy.

Williams said he understands there is additional effort for people who need to consult with doctors about switching to generics or lower-cost alternatives. But he said the EUTF, which is spending more than $600 million a year providing coverage for members, had to look for ways to slow rapidly increasing costs.

That's fine with Don Hutchinson, a Kaimuki resident who said he was happy with using the antihistamine Fexofenadine but will face a higher copayment if he doesn't switch to Claritin or Claritin D.

While the convenience of using a mail-order pharmacy is appealing to him, Hutchinson said he doesn't like feeling that he's being coerced to switch prescriptions.

Hutchison said he is going to give the new drug a try.

"If the Claritin works out OK, then that's fine with me," Hutchison said.

But "if I don't like Claritin, I'll be upset."