Recently, I went to see my primary care doctor about my reflux because despite my treatment with over the counter H2 blockers, I was experiencing severe abdominal pain. He suspected an ulcer and referred me to a Gastroenterologist (GI). He then gave me 10 days worth of Dexilant (a dual release Proton Pump Inhibitor) as a free sample.
Freebies - we all love them. It’s nice to have a sample of a medication before having to pay for something that may not work. When I got home, I looked up this medication and realized it is a more complex version of Prevacid in that it has two releases of medication. I then looked up my formulary (approved medications through my prescription plan) and realized that Dexilant is non-formulary drug. For some people this means your insurance won’t pay for the medication. For me it means $40/month vs. generic Prevacid (lansoprazole) at $10/month.
This all got me thinking about the whole medication process. Drug companies need to make money because it costs a lot of money to develop new medications. If there is no financial benefit for the companies, they will cease to try to develop new drugs which obviously would be disastrous. The way they make money is by coming up with new drugs and then convincing doctors and patients why this drug would work. Some of this we see in advertisements on TV an in magazines but much of the advertising is done when drug representatives bring free samples to doctors. These drug representatives explain their medication to the doctors and then leave samples for them to hand out to patients. Of course, the intent is that the doctor will appropriately hand out the free sample, it will work and the doctor will then write a prescription for that medication.
What then often happens is that the patient takes the medication to the pharmacy and it is either rejected or the patient pays a higher than normal copay for the medication. If the medication is outright rejected by the insurance company the patient will often feel like the insurance company is calling the shots and unwilling to give them the drug they "need."
So, how did I handle this situation? I printed out my formulary and took it with me to my GI visit. On my formulary, generic Prilosec (omeprazole), generic Prevacid or brand name Nexium were offered as alternatives. As Prevacid had worked well for me in the past, I asked the doctor for generic Prevacid. If it works, this will lead to a substantial savings for me as well as my insurance company and healthcare overall. If it doesn’t work, I may need to try something different and may need to pay additional money for my prescription. But, by being proactive and understanding the system, I did not wind up in a position of feeling like I was being denied something I "needed."
It pays to know about what is covered by your prescription drug plan and to take your formulary list with you. Remember that while your insurance company does want to keep costs low, it benefits everyone when we choose the least costly but still effective option.