Painting and Decorating Made Easier!

I’m about ready to pull my graying  hair out, and go bald.

 

I take a Brand name medication that requires a prescribing MD’s prior-authorization request to access. Suddenly, the M.D. decided to stop completing and submitting a prior-authorization form for the Brand name to the insurance company.

 

“Totally unnecessary. Generic is exactly the same as brand name.”

 

What was that? Try to convince the Major Pharmas of that one!

 

Take note, fellow healthcare consumers:

 

As of the end of 2015, over 3 billion, 874 million* Americans take a generic form of a Brand name prescription drug. The National Prescription Audit’s most recent report** shows that 84.3 percent of prescription sales are the generic compound. Total generic sales topped $1.7 trillion dollars between 2005 and 2014.

 

At least 70 percent of those 3,874,000 are taking the generic, versus Brand compound, because of one or more of the following reasons.

 

  1. Their insurance company – eg. employer group, individual, family, Medicare, HMO – approves and has in its RX formulary only the generic versions of the Brand name prescription.

 

  1. Their healthcare provider will not order the Brand name as – eg. “medically necessary,” “Fill with RX Brand only,” etc. Note: See “Important Note” below.

 

  1. The patients cannot afford the cost of the Brand name pharmaceutical products.

 

  1. The local in-network pharmacies carry, or will order, only the generic version(s) of the Brand name product.

 

  1. The healthcare provider’s group, and its insurance company, will not certify the physicians in the group to write prior-authorization requests for and to prescribe Brand name products, when a generic is available. Note: See “Important Note” below.

 

Important Note: This includes if and when the patient tries and cannot take any of the generic (s) of the Brand name product. This includes if and when the patient has tried and retried, unsuccessfully, to take all of the generic compounds on the market. This can even include when a hospital consulting specialist determines that a patient must go back to taking the Brand name product.

 

One smaller health insurance company has found a solution. Well, it would appear to be one…

 

In its pharmacy formulary, the company includes a “suspension”/liquid form of a particular Brand name product. It is considered a compounded, “Specialty drug. At a Specialty drug tier/level price. This tier or level usually carries the highest price drugs in the insurance company’s pharmacy formulary.

 

A patient is caught in a bind. No choices that really benefit him or her.

 

Five of the Patient’s Options

 

  1. The patient can take and stay on a generic, regardless of adverse reactions, interactions, etc.

 

  1. The patient can self-pay 100 percent of the retail cost of the Brand name prescription drug.

 

  1. The patient can order the Brand name product from a Canadian pharmacy, hopefully one with a good track record for prompt delivery and sound ethical practices.

 

  1. The patient can change from the prescribing physician to one that will submit that prior authorization request for Brand name only.

 

  1. The patient can switch to a similar Brand name product that is in the insurance company’s pharmacy formulary, and does not require a prior authorization.

          Cautions: A.Most Brand name products listed in the formulary will require prior-authorization.                 B. Also, many newer Brand options come with much higher price tags.

 

What about simply changing your medication?

TIP: It may be wise to change from a medication that’s working only if you have to do so.

 

Real World Scenario. It’s very interesting to see and hear the reaction of another, leading healthcare provider, when told that a prescribing physician refuses to support an established patient’s need to stay on a Brand name prescription medication.

 

M.D.: “Did he/she say why?”

PATIENT: “I won’t do it…It’s totally unnecessary. Generic is exactly the same as Brand.”

M.D.: Tilt of his head…His eyes lower…He shakes his head left-to-right. “Hummmm.”

 

Guess what! A few poignant letters, including to the company’s president/ceo and group medical director may have gotten them all talking again, and rethinking their prior authorization policies. We’ll let you know. Keep your patient/healthcare consumer fingers crossed.

 

SOURCES

* “Statista Report on (Generic) Pharmaceutical Products and Markets, for 2015.”

* Also, The Generic Pharmaceutical Association.

** National Prescription Audit (for Generics), Report May, 2016.

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Responsible healthcare boils down to responsive treatment of the patient.

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Many thanks for trying to do your best in your world.

And, thanks for visiting “Painting with Bob.”

Copyright 2016. Robert D. Hajtovik. All rights reserved.

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