American Glaucoma Society
Position Statement on Glaucoma Eye Drop Availability
In recent months, changes in our health care system are creating unintended consequences for glaucoma patients who rely upon drug plans to provide them with their glaucoma medications. Many of these patients are being denied adequate supplies of their glaucoma eye drops due to tighter restrictions on refills. The current monthly volumes of eye drops allowed by health plans are often inadequate due to the common and inadvertent wastage of drops when eye drops are applied to the eye. Chronic medical therapy of glaucoma is a critical and cost-effective first line of treatment. Gaps in the treatment of glaucoma can lead to vision loss and blindness. This statement is submitted on behalf of members of the American Glaucoma Society (AGS), an organization of over 500 ophthalmologists who specialize in glaucoma care and surgery, and the American Academy of Ophthalmology (Academy), the world’s largest association of over 29,000 eye physicians and surgeons. We are committed to providing optimum care for the glaucoma patient.
Pharmacy benefit programs with Medicare Part D and non-Medicare commercial health insurance now have stricter limitations on the frequency of refills of medications prescribed for chronic conditions. Plans restrict patients from refilling medications earlier than the single month or 90 day refill date. The number of drops in various bottles of glaucoma medications is known and despite the fact that bottles may contain more drops than the prescribed dosage, there are numerous reports of patients running out of drops prematurely and unable to obtain refills prior to the allowed refill date. This often leads to patients not taking their eye drops until the next refill is allowed by their drug plan, creating a gap in care where the patient’s disease may worsen. The American Glaucoma Society and American Academy of Ophthalmology are very concerned about the inadequate access to necessary medication for chronic treatment of glaucoma.
In the United States there are millions of patients treated with topical eye medications each year. In the treatment of glaucoma, almost 75% are treated with more than one medication simultaneously for long periods of time, often years. It has long been recognized that non-adherence is a significant roadblock to successful treatment of patients even when appropriate medications are easily available. Inadequately treated glaucoma leads to vision impairment and blindness. Although there are patients who are vigilant in taking their eye drops regularly and on schedule, ophthalmology is unique, however, as even compliant patients may not be able to administer eye drops correctly and may waste significant volume every day. Unlike pills, eye drops are less reliable drug delivery systems. We have found that, even in experienced glaucoma patients who self administer their eye drops, between 53 and 61% regularly administer more than one drop at a time, many without even realizing it. These numbers are increased in those with poor vision from glaucoma, cataract, or retinal diseases. 80% to 88% of these patients with visual comorbidities are unable to adequately instill a single eye drop at a time.
Physical disabilities can also interfere with the administration of eye drops. It is particularly difficult for older patients to master and perform this task proficiently. Eye drop administration requires both the technical ability to easily squeeze out a single drop and the hand-eye coordination to find the eye and squeeze the drop onto the eye. Regrettably in older individuals where glaucoma is common, diseases such as arthritis, tremor, Parkinson's and other musculoskeletal problems make it difficult to accurately squeeze the bottle to administer just a single drop. It is not uncommon for some patients to require double the allowed volume.
Ophthalmologists are increasingly aware that restrictions on medication availability are a component of poor outcomes in the treatment of glaucoma. It is well-recognized that increased cost is associated with lack of adherence. Expecting the patient to pay full retail prices out of pocket for additional medication to cover the refill gap is not realistic, even if the patient is made aware that such an option exists.
Glaucoma patients who go untreated, even for relatively short periods of time, run the risk of worsening vision loss in the future and increase the likelihood of requiring surgical intervention for their disease. Surgical intervention carries greater risk than chronic medical therapy and increases health care costs. Vision loss from glaucoma has been associated with an increase in the rates of falls, depression, and nursing home admissions.
The AGS and Academy entreat the health insurers with pharmacy benefit plans and their pharmacy benefit managers to study this issue further and reevaluate their refill policies for eye drop medications. Time restrictions for refills of eye drop medications for serious eye diseases should be lifted until further study has been made. Strategies to increase eye drop availability should be immediately instituted to prevent interruption and gaps in treatment for our patients.
American Academy of Ophthalmology and American Glaucoma Society
BOD Approved – 09.01.2009