I got an unusual request last week. I had written a prescription of a generic medication (which has been generic for a couple of years) and the prescription was denied by the insurance carrier. The reason for denial: I had to try a brand-name medication first.
Stop. Read that again. They wouldn’t allow me to give a prescription for the (cheaper) generic drug because I had to try the brand-name medication first. This is opposite of the usual reason for denial, the availability of a cheaper alternative than the prescribed drug, and, to my knowledge, is the first time I have ever seen it upside-down like this, and I have been in the ring for the duration of the drug formulary death cage match of awesomeness. I’ve seen it all unfold.
Here is what happened.
I am not, like many physicians and patients, against the idea of cost-control through the use of drug formularies. Medications are very expensive (unnecessarily expensive, as I have discussed previously), and the previously strong influence of drug reps made many doctors quick to jump for the latest and greatest medication. I did this myself, during the first few years of practice – before the advent of drug formularies.
We were constantly detailed on new NSAID’s, antibiotics, cholesterol, and blood pressure pills. There was always a reason the latest drug was worth using over the old one (sounds a lot like fancy smart phones, doesn’t it?), and since insurance paid the same for brand drugs, I was often influenced by the drug reps.
The distribution of prescription pharmaceuticals is beginning to take on some of the characteristics of online videos and music. Traditionally, access to prescriptions works as follows:
Patient has a problem
Patients sees his/her physician
Physician diagnoses problem and writes prescription
Patient takes prescription to traditional pharmacy or PBM-owned mail order company
Pharmacy fills prescription with a drug manufactured by an FDA-regulated brand name or generic pharmaceutical company
Patient takes medication
If patient needs more medication after initial prescription and refills are exhausted, patient requests renewal from physician and repeats steps 4 to 7
But steps 2 through 7 are breaking down. Instead of seeing their physicians, increasing numbers of patients are either going directly online to order from pharmacies or are borrowing pills from friends and family who’ve received prescriptions. According to MedPage Today (Adults Commonly Share Prescription Drugs with Friends and Family) almost 30 percent of adults reported sharing prescription medications with others. Younger people are the most likely to share.
Meanwhile, shady web-based pharmacies that don’t require prescriptions and often sell counterfeit drugs are becoming increasingly sophisticated and impressive. MarketMonitor estimates that about 1000 shady pharmacy sites generate an average of 100,000 hits per day each and that such pharmacies spend about $25 million per year on search advertising. An acquaintance who works in the pharmaceutical security business told me that these pharmacies aren’t what they used to be. In fact they are adopting marketing and customer service best practices that are used by legitimate vendors. Rather than going for a quick score, the web-based companies are looking for repeat business and word-of-mouth referrals by providing products that work, offering easy-to-navigate websites and low prices.
Many of the breakthrough drugs of the 1980-1990′s are now available
as generics, and pharmacy competition has led to great bargains for
patients needing these drugs.
The 1980’s and 1990’s were a golden age in the development of great
new drugs to treat many common and uncommon diseases. Prior to that
time it was very difficult to treat depression, hypertension,
diabetes, and congestive
heart failure. It was nearly impossible to treat high cholesterol.
Breakthrough drugs like the SSRI
inhibitors and calcium
channel blockers for hypertension, metformin
for diabetes, and several drugs in combination for congestive heart
failure came to market, and have revolutionized the care of many of
these chronic diseases. Now the great news it that many of these drugs
are available as generics, and competition between retail pharmacies has
led to incredibly cheap medication. Here is my top ten list of great
ACE inhibitors. I tend to use lisinopril, but
several others are also available. These meds are effective at
controlling high blood pressure, but have also been shown to prevent
heart attacks in patients post MI, to prolong life and reduce
hospitalizations in congestive heart failure, to prevent diabetes
related kidney failure, and is usually extremely well tolerated. A
small percent of patients get a cough, and even smaller percent are
allergic to these medications.
Statins This class of LDL cholesterol lowering drugs has made effective treatment of high cholesterol practical and simple. Several have gone generic including simvastatin, lovastatin, and pravastatin. Although simvastatin (Zocor) is not on the chain pharmacy $4. drug lists, it is quite inexpensive ($10.90/ 100 40mg doses at Costco) and is effective enough for most patients to achieve goal LDL cholesterol levels. Many studies have shown statins to be effective at lowering rates of various cardiovascular diseases.