One of the most frustrating experiences that I encounter regularly is when I formulate a treatment plan. I determine a specific medication and dosage, often through trial and error and after many office visits, taking into account issues including side effects and efficacy of the drug therapy. Then, after all that effort, I get a phone call from either the patient or the pharmacy saying that “this medication is not covered by the insurance, so can you change it?”
That single phone call essentially undoes all of my analyses and prescribing efforts and I now have to start all over. It feels like the perception is that I can change the treatment just like changing to another brand of toothpaste.
In some conditions like hypertension, there are some reasonable swap out drug options that don’t require too much further investigation. In the case of diabetes, it is nearly impossible to exchange medications without starting the whole treatment evaluation process again. That’s because each family of medication is so drastically different. A simple phone call to swap out a different medication is not feasible.
When it comes to treating asthma, there are additional considerations. It’s not only the choice of medication, but also the delivery device that is used by the patient, that requires re-analysis. There are basically three different classes of medications that are delivered through inhalers. Inhalers are the first line of treatment of asthma since you can deliver the medicine to the lungs and limit side effects.
The new choices of inhalers include a combination of two, sometimes three medications in one inhaler device, with the added convenience that one inhalation will last the whole day. In addition to the choice of medications, the patient needs to be shown the proper way of using the inhaler. Each one is different.
When the pharmacy calls and requests a “change to another inhaler” the implications are many. If it’s a combination inhaler, I need to analyze its individual medication components and now give two different inhalers. The new choices are often medications requiring two or three doses daily (each). If the new drug choices are being dispensed in different inhalers, new instructions for use also need to be given.
The pharmacist will often say to me, “Please order the generic version.” That’s because patents on brand name drugs last for years, even decades, and those proprietary formulations are licensed only to one company. That monopoly means its typically more expensive. But when I’m asked to swap out that inhaler for another cheaper unbranded inhaler(s), it’s just not an easy swap.
Sometimes a different company develops another drug within the same family of the brand name drug, usually by making small changes in the formula. Despite the minimal adjustments to the drug, the company still has to go through a costly process of doing studies on this new version for FDA approval. That process costs money, so the drug is often not a whole lot cheaper than the original branded version. But at least it offers an alternative.
The patent on a brand name drug can finally expire, allowing other companies to make the same drug. They can’t use the “brand name,” so they identify their drug as generic – which basically means it can be swapped out for the brand name and it is often cheaper. There are large pharmaceutical companies who specialize in making generic drugs.
It can be confusing to the patient who sometimes thinks that the generic drug is be sub-par because it’s not “brand name,” but ultimately many patients will want the generic, cheaper option. The truth is that there’s not much difference in the drug quality since generic drugs are often manufactured in the same factories as the brand name drug.
Most insurance plans encourage the use of (cheaper) drugs that are available in generic form by charging lower co-payments, or simply eliminating brand name drugs from their formulary.
So why wouldn’t a doctor just prescribe drugs that the insurance includes on its approved list – the mostly less expensive, generic drugs?
It’s not always that simple. In some cases, only brand name is available – there is no generic version. This is especially the case for diabetes drugs and for many cardiac medications. In the case of asthma, there is a distinction between the long-acting medications which are used as controllers - medications to be taken on a regular basis to avoid asthma attack, and short and fast-acting medications, which are indicated and only used when there is an acute need - rescue medications.
Rescue medication have been around for some time and have generic options. It would be inaccurate and frankly subpar to suggest using rescue medication three or four times per day as swap out or equivalent to taking the long-acting controller medication once-a-day. Yet this is often what the insurance plans ask from me when they suggest the replacement of a brand name controller drug with a generic rescue drug.
The pharmacist will be subtle and tell the patient that “if you want the doctors prescribed drug choice, you will simply have to pay more money for it, or the doctor will have to get an authorization of coverage from your insurance company for this brand name drug.” That means I have to get on the phone, send paperwork and take extraordinary time to show that attempts of treatment with other drugs have been made and failed.
No doctor wants to put a patient on drugs that will not control the asthma “to prove” the need for other drugs. Or I have to anticipate problems and get my assistant to fill out extensive paperwork and a prior authorization in order to justify the cost to the insurance company. That’s incredibly time-consuming and can delay indicated treatment. Doctors also have little leverage in the conversation. Insurance companies analyze the market and their bottom line when they make formulary decisions.
Approved medication choices that I receive from an insurance company can also change yearly, without warning. This is due to a variety of factors that govern the fluctuating pricing of drugs. The bottom line is that it affects my goal of optimal prescribing habits.
To deal with these confounding issues in healthcare I recommend discussing the choices of medications with your doctor. Weigh convenience and cost and make an informed decision by learning about the medications recommended to you. Especially learn about long-acting and short-acting drugs so you understand the need for your personalized regimen.
Certain drug programs direct from the pharmaceutical, online companies like GoodRx that offers coupons and BlinkHealth which cuts out the middleman in drug pricing and offers direct from pharma pricing through bulk pricing negotiations, may offer some cost breaks on even brand name drugs.
Your choices of medications are important to your health. You are dealing with a health insurance system that wants to reduce their costs. Be proactive in your needs and work with your doctor to get the most optimal treatments and drugs.