A New Drug Class: Will Marijuana Find Itself on a Plan’s Formulary?

AJPB® Translating Evidence-Based Research Into Value-Based Decisions®September/October 2014
Volume 6
Issue 5

One day health plans may cover medical marijuana in states where the drug has been legalized, but there are still barriers to overcome.

It has often been said that physicians are the greatest influencers of which medications are prescribed to patients due to their “power of the pen.” Over the years, this sway has created an environment in which pharmaceutical manufacturers and healthcare insurers spend a great deal of time and money on “educating” the provider regarding the drug choices that they are making.

This may seem silly to you but I want you to think about it for a minute. There is good medical evidence that medical marijuana is effective for glaucoma, cancer, and at least 35 other medical conditions. Two states, Washington and Colorado, have made the drug legal in general and 21 states have legalized medical marijuana. The days of only “stoners” smoking or ingesting marijuana are changing, as are attitudes. Acceptance of marijuana has been increasing.

This increasing use of medical marijuana, both legally and illegally, creates a number of questions. First, will health plans begin covering medicinal marijuana in states where it has been legalized? You may laugh, but in fact, Susan Pisano, a spokeswoman for America’s Health Insurance Plans, has been asked this question. Today, insurers have a number of barriers to overcome before even considering the idea.

1. Marijuana remains illegal federally. This has created a significant amount of confusion in states where it has been legalized either for medicinal purposes or for recreational purposes.

2. Most health plans do not cover any medications that are not FDA approved. As we all know, FDA approval requires expensive clinical studies focused on safety and efficacy.

3. Those who support the use of marijuana for medical purposes cite research that shows that it is effective. They also point out that there are FDA-approved medications that use part of the marijuana plant. Marino, an appetite stimulant for patients with AIDS, contains tetrahydrocannabinol, which is an active ingredient of marijuana.

4. Today, marijuana is considered a Schedule 1 controlled substance due to its high potential for abuse and the belief that it has no accepted medical use.

Interestingly, the American Medical Association (AMA) seems a bit more open to considering the idea of marijuana as a potentially reasonable medication for their patients. The AMA has asked for a change in marijuana’s classification so that studies can be done to better answer the questions around safety and efficacy. Currently, physicians cannot prescribe marijuana. Even in states where it is legal, they can only recommend it.

These issues have spread outside of the medical community to include our courts of law. In 2012 a case was brought before the United States Court of Appeals for the DC Circuit in an attempt to change the Schedule 1 classification. The appeal was unsuccessful but the conversation continues.

A second question that arises is that of the quality and consistency of marijuana.

Today, there are no standards associated with consistency in strength or in quality. This becomes a challenge in both safety and efficacy. How does a physician prescribe it and how does a patient know how much to take? This is a question that needs to be answered prior to widespread coverage of medicinal marijuana.


Medical marijuana can be costly. Some utilizers of the drug are spending in excess of $100 per day. That being said, many of the medications that it would be replacing are also expensive. In fact, for some people it would take only a small amount of marijuana to address their medical needs and this could actually save them money.

So how do you estimate the cost of the drug? Today, the cost of medical marijuana is not regulated. Each dispensary charges what the market will bear. In order for the drug to be covered, it is likely that some cost regulations will need to be put in place. If that does not occur, a cost and coverage protocol for health plans needs to be designed, as has been discussed for years now.


Will marijuana be coming to a pharmacy near you? Pharmacy.com found that 70% of respondents to a questionnaire said that a retail pharmacy would be their preferred choice for purchasing marijuana if legal.

Like other state and federal laws, pharmacist licensure would have to change. Like medical doctors who cannot actually prescribe marijuana, pharmacists are prohibited from dispensing marijuana. Today, pharmacists are used to counseling on medications and dispense controlled substances. In addition, they give advice on OTC herbs and vitamins, which are also not regulated by the FDA. It is not that far-fetched to consider pharmacists dispensing marijuana for medical use.

A number of retail pharmacies have begun to research their ability to dispense marijuana in states where it is legal. It is not as easy as one would think. Even in states where marijuana has become legal for medicinal use, it is not easy for dispensaries to open their doors. It is a complicated process and one I will not go into here. That being said, don’t be surprised to see the retail pharmacies wanting to get involved.

A Look Into the Future

I do believe that the time will come when we see health plans cover medical marijuana. How do I see this working?

1. States would need to adopt rules governing a patient’s ongoing relationship to a physician. New Hampshire, for example, stipulates that a patient must have at least a 90-day relationship with the physician.

2. The physician must have special training in the uses of marijuana. This type of requirement has been used with certain medications that are high risk.

3. Coverage of medical marijuana would be for those conditions where there is consensus of efficacy. In Connecticut, for example, a patient must have one of 11 conditions in order to buy medicinal marijuana.

4. The patient must have tried other medications without relief of symptoms.

5. Patients would have to get their medical marijuana at a pre-approved dispensary or pharmacy.

None of these rules are unenforceable. In fact, they look very similar to other medications that contain prior authorization and narrow network coverage.

Let the conversation continue. It may not happen today or tomorrow, but I believe that in the not-too-distant future, health plans will try to differentiate themselves by covering medicinal marijuana.

What do you think?

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