An Open Letter to CIGNA

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I hear you are buying Express Scripts. This letter is a plea from a former Express Scripts customer to closely scrutinize their business practices, which, during the time I patronized them, were burdensome at best and actively harmful at worst. I am not talking about a “simple” denial of services, but policies that substituted the company’s experts, whomever they were, for both the judgment of a provider who knew the case, and long-accepted medical standards.

Several years ago, my former employer switched pharmacy benefit management (PMB) organizations after only three years, from Express Scripts to CVS. For a company with over 20,000 employees, that was an incredibly short span for such a cumbersome change. I suspect it had more to do with employee complaints than some kind of better deal. In my account alone, the lighter transgressions consisted of: dropping two asthma medications in the space of a year, discontinuing access to the type of insulin that was specifically engineered to work well in insulin pumps, and changing the policy for blood glucose testing strips to go from rounding up to rounding down. The latter cost me 100 strips per quarter, which is a lot for someone who tested 8-10 times a day.

With my background, I always understood that plan coverage fluctuates. It is the literal cost of doing business. The real issue with all of those changes was that they were implemented in the middle of calendar years without notification. In fact, I knew nothing of any of these changes until I tried to renew the various prescriptions.

But as I mentioned, this was not the most egregious thing Express Scripts did. No, that label is reserved for the fiasco that occurred around Aranesp. Aranesp is an expensive anemia treatment often administered to cancer patients by a physician to counteract the effects of chemotherapy. In July 2012, The Washington Post published an expose detailing how Amgen, which makes Aranesp, was inflating costs, and some medical providers were purposely misusing it to make a bigger profit. As a result (presumably), Express Scripts acted to limit access to Aranesp across the board, lumping all patients who used it into one group.

Huge violation all the way around, I know, and all of those who were taking advantage of the system should have been investigated and punished. However, there were those of us with milder conditions than cancer or kidney failure (another common cause of anemia) who self-administered very small doses. We required a blood test and prior authorization for each prescription refill. Under those circumstances, the chances of us abusing our insurance plans was virtually nil.

Shortly after that article was published, Express Scripts instituted a policy where they decided they knew better than the entire medical community, as well as the patient’s (sometimes multiple) doctors, who were more familiar with the details of individual cases. Against the protests of both patients and doctors, they lowered the qualification for receiving Aranesp from a hemoglobin result of 11 to a 10, effectively putting it out of reach for those of us without severe anemia. No matter how many appeals Express Scripts received, they would make no exceptions for me or any of my doctors’ other patients.

Maybe to Express Scripts, it didn’t seem like such a big deal. It was just a point’s difference. Many of us with chronic condition-induced anemia fell into that category. We had mild cases, but we couldn’t fix it with more leafy greens and red meat. And I can’t take iron pills or liquid. They all give me a rash. Ironic, isn’t it? An anemic who can’t tolerate taking iron. I even tried putting the liquid in Jell-O. Tasted like I was sucking on pennies. And it still gave me a rash.

What did that mean for me? Sometimes I struggled for breath, and I felt sluggish and foggy all the time, which affected my job performance. It wasn’t a great quality of life then, and so easily fixable. The low likelihood of misuse should have warranted at least an individual assessment. But no, Express Scripts lumped us all together, as if all patients and all diseases were equal. But we are individuals, with individual needs and diseases that are as unique as fingerprints.

As far as I am concerned, what Express Scripts did in 2012 was ethically and morally wrong. So, please, as our healthcare system turns to a more value-based, patient-inclusive model, I implore you to closely evaluate all of Express Scripts’ harmful policies and decide what is right, not just for your business, but also for the patients who have no other choice but to use it.


Claire Sachs

Founder, The Patient Advocate’s Chronicle