"Humana, I want my Premarin!"

This past Tuesday’s Wall Street Journal had an article about two important new web sites in the area of health care.  According to Health Journal writer Melinda Beck, “A start-up company, AdverseEvents Inc., has streamlined the FDA’s often impenetrable database and made it easy to search the adverse-event reports for more than 4,500 drugs, free and online.”  Another start-up, Clarimed LLC, has done the same for reports filed with the FDA on 130,000 medical devices….”  The new web sites created by these companies will be a welcome change for those of us who sift through the masses of information to try to get at the facts about available medical treatments.

During the past few days I have been in the sifting business myself.  Last June, when I turned 65 and went on Medicare, I selected Humana as my drug insurance provider.  For Humana, I should be a pretty good deal:  there are only two medications I take year-round and I rarely need any others.  The ones I take are Synthroid, because I’m hypothyroid, and Premarin, an estrogen-only form of hormone replacement therapy.  I started on Premarin in 1979 after a complete hysterectomy at age 32.  At first I resisted taking it, but my doctor at the time said that I needed it in order to maintain my bone density.  Over the past 30-plus years the pendulum has swung back and forth on HRT.  In 2002 the Women’s Health initiative study of estrogen-plus-progestin was halted when women taking the medication had 8 per 10,000 more cases of breast cancer than those in the placebo group. 

The publicity resulting from this study caused women to abandon HRT in droves, but not me.  Since I was taking an estrogen-only version, it wasn’t clear that these results applied to my situation.  Further research has led to a more nuanced view of the risks and benefits of HRT.  On the plus side, it lowers the risk of osteoporosis, diabetes, and colon cancer, as well as treating post-menopausal symptoms like hot flashes and mood swings.  In healthy women it may also help reduce atherosclerosis and inflammation, which can lead to heart disease.  This last part is of great interest to me because people in my family get heart disease.  On the negative side, there is a small increased risk of stroke and pulmonary embolism,  12 more cases of stroke per 10,000 and 6 more cases of blood clots in the legs, according to the Mayo Clinic web site.

A few weeks ago I ordered a renewal of my Premarin prescription.  Last week I learned that Humana has taken it off its formulary; they will no longer pay for it unless you get a prior authorization.  Instead, they are offering some version of Estradiol, a different form of estrogen therapy.  Right away I started doing research.  If Estradiol were basically similar to Premarin, as a generic would be, I might be willing to change.  They’re not similar, though, and there’s no generic for Premarin.  I looked at the comments of women who had taken one or both products.  The majority of reviews for both products were favorable but most women who had taken both preferred Premarin.

On Humana’s side, I can understand the rationale for discontinuing their coverage of Premarin.  Like other, older generation HRT treatments, its reputation was tarnished by the WHI study and its fallout.  Moreover, the current recommendation for prescribing estrogen treatment has changed; women are now advised to take it for a few years after menopause to deal with post-menopausal symptoms and then discontinue it.  Women with low bone density are steered toward bisphosphonates such a Fosamax.

For me, it is much too late to discontinue Premarin after a short time; I’ve been on it for almost 33 years.  I’ve been healthy during that time and am in better shape than the average 65-year-old woman.  I have no sign of heart disease and my bone density, though on the low side, is stable.  How much of this is the result of my Premarin use no one can say, nor can anyone predict whether I would do as well on some version of Estradiol.  Premarin, which has been around since 1942, has been studied a lot; it is a known quantity, both in general and for me personally.  Taking a new medication might cause subtle changes whose consequences might not be apparent for years.  I hope that Humana will reconsider its decision.  As a practical matter, medical research needs to deal with broad categories of people but medical treatment must be based on the specific needs of the individual. 

UPDATE 2/9/2012  My doctor's office told me that they faxed Humana's prior authorization form on 2/13/2011.  Today they made a follow-up call and learned that the fax number given on the form was not correct.  The form has now been faxed to the correct number.

UPDATE 2/10/2012  Humana has sent me a wall calendar with helpful reminders about taking my medicine as prescribed, etc. 

UPDATE 2/16/2012  After numerous conversations and several faxes among Humana, my doctor's office, and me, the request for Premarin has been denied twice.  I am now initiating an appeal.  Keeping me on Premarin seems like a win/win situation for Humana and me; without Premarin I might end up needing medication for both heart disease and osteoporosis.  Why is this so difficult?

UPDATE 12/11/2014 "Humana, I Still Want My Premarin - So I Wrote to Medicare" and the two sequels.