Insurer pulls plug on drug for menopause
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By ROBIN PALMER Staff Writer - Published: July 17, 2005
Debbie Ciarcia has been taking hormones since she had a hysterectomy nearly a quarter century ago at age 29.
She's used the now-controversial Premarin and a hormone patch. She's even tried over-the-counter products and health food store supplements. But none of these products cured the 53-year-old's hot flashes, night sweats, mood swings and mental fogginess – until estriol, she says.
Estriol is a natural occurring form of estrogen contained in a product pharmacists create called "tri-est," or triple estrogen.
"I was on it four days, (and) it was like a light bulb went on. Everything stopped. I was like a different person. The crying stopped. The mood swings stopped," says Ciarcia of her experience with estriol.
But now that she's found a cure, something else is making the Jeffersonville woman hot under the collar: Her health insurer, Blue Cross and Blue Shield of Vermont, has stopped covering the drug.
In late May, Blue Cross and Blue Shield's prescription benefit manager, partner company Restat, sent a notice to the insurer notifying it that estriol would not be covered effective May 31, because the product is not approved by the Food and Drug Administration, says Kevin Goddard, vice president of external affairs for Blue Cross and Blue Shield of Vermont. Based in Berlin, Blue Cross and Blue Shield is the state's largest health insurer.
"We don't pay for experimental treatments and therapies," Goddard says. While Blue Cross and Blue Shield is in no way calling the product unsafe, he says, "We have no way of evaluating the drug itself, so we like to rely on … the FDA."
Pharmacists and Blue Cross and Blue Shield members are floored by the change in coverage.
Victoria Weber of Bethel says it unfairly targets menopausal women trying to make a healthier choice and the small pharmacies that help them get the drug. Weber, who is a Blue Cross and Blue Shield member, fills her estriol prescription at the Custom Prescription Shoppe in South Burlington.
Scott Brown, the owner of Custom Prescription, called the health insurer's decision "ridiculous."
Other compounding pharmacists agree. Compounding pharmacists make prescriptions in concentrations, dosage forms and make-ups not otherwise commercially available, Brown explains. Examples include dye-, preservative- and sugar-free products for patients with special needs; small concentrations of particular drugs for children and half-size doses for patients who have difficulty cutting pills in half.
Brown's shop is one of more than 3,000 compounding pharmacies in the United States and several in Vermont, he says.
He estimates that products containing estriol make up 40 percent of claims submitted to Blue Cross and Blue Shield by his customers and that up to 100 women he serves will be affected by the change.
"It's been a big deal for our pharmacy," he says.
He estimates that several hundred women in the state are affected by Blue Cross and Blue Shield's coverage change.
"It's commonly used by alternative practitioners and naturopathic physicians," he says of estriol. Brown says he believes estriol is a safe product, noting that it was previously approved by the FDA.
Compounding pharmacist Randy Pratico, manager of Wilcox Pharmacy in Rutland, calls estriol a "bio-identical" hormone, or one that is identical to what is in the human body. Estriol, he says, is extracted from plants, such as soy and yam. It can be compared to Premarin, now thought to increase the risk of developing uterine cancer.
"Many, many women are on that now, not just with us, but statewide and countrywide," Pratico says of estriol. "It just seems like a great alternative to the synthetic hormones, like Premarin."
Pratico says he was not aware of the change in Blue Cross and Blue Shield's policy.
That's not surprising. Initially, Goddard said, the insurer had made no change and, in fact, was covering more estrogen products. He later said he had been mistaken and had just learned that estriol was no longer covered under his company's prescription drug policies. A Blue Cross and Blue Shield representative also told Ciarcia that she would be reimbursed for estriol.
In the end, she was not repaid for the medication, she says.
"That's ridiculous," says Pratico. "It helps so many women. Blue Cross and Blue Shield pushes the envelope sometimes."
Ciarcia alleges it's all about money. "But they don't mind taking your premiums," she says.
She says she paid $12.40 a month for her estriol medication, "tri-est," after Blue Cross and Blue Shield's reimbursement. She's now paying $65 per month.
Ciarcia, who is currently out of work and caring for a grandchild while her son is in the military, says she can't afford estriol without the insurance reimbursement. But she also can't afford not to take it. "I know how well this works for me," she says.
Her doctor took her off estrogen drugs last fall because of the controversy surrounding them and her years of use without much relief. Two months ago she entered a Burlington gynecologist's office "bawling" due to out of control menopause symptoms and was put on estriol.
Brown, who says he has talked to compounding pharmacists in other states who are having the same issue with Blue Cross and Blue Shield, is assembling information on estriol to send to the insurer, hoping it changes the Vermont company's stance, he says.
And Ciarcia is working to file a complaint on behalf of the Custom Prescription Shoppe customers with the state's Department of Banking, Insurance, Securities and Health Care Administration, she says.
"I'm just tired of people taking advantage. They think menopause is no big deal. People just don't understand. They don't get it. For 24 hours, I'd like a man to be a woman and be in menopause and see," she says.
She may be wishing that on Goddard next. He says Blue Cross and Blue Shield of Vermont won't be changing its policy, unless estriol becomes FDA approved.
Contact Robin Palmer at robin.palmer@timesargus.com or 479-0191, ext. 1171.
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