Saying No to Insurance Company Medication Switches
I can not say I have been exposed to any of this switcheroo as my meds are older technology. We are also on regular Medicare and not Medicare Advantage. I have a larger say with the former. Part D works mostly except the pharmacies in my area are less helpful than they were in Michigan. And these drugs do seem to work to my needs for now.
Doctor Pelzman does have a major point. The insurance companies, PBMs, distributors (McKesson, etc.) have a growing say in what is being prescribed to patients. Patients – the above-named commercial interests know little about other than the patient has a disorder, disease, etc. And the suggested new med is profitable for us and it “may” have a “similar” impact. Your old drug may now have a higher co-pay (to get you to switch to our preferred drug). You can switch to the mail-order provider. Eliminate much of your co-pay (for now), and have it mailed late to you. The drug company will blame the USPS if late.
Your personal doctor whom you trust is slowly being incorporated into the pharmaceutical companies and distribution systems. They can either abide by the pharma dictates or get frustrated by having to call them up constantly. It is not guaranteed they will get anyone knowledgeable on the phone as the other end follows the insurance formulary. The insurance company got a better deal with the new drug. Your old drug went to a new tier which also has a higher copay. The old drug company would not negotiate pricing.
Enough of my diatribe here. Read the article by Dr. Pelzman. I experienced occasional issues with my local pharmacy. Also be sure to read the comments by medical personal in the Commentary section too.
“‘Just Say No’ to the Medication Switches,” MedPage Today, Fred Pelzman, MD, Contributing Writer
No. Just no.
As the start of the new year has come around and gone, I’m sure you all, like me, have been inundated with the ritual beginning of the year change of prescription requests.
- “The Lantus (glargine insulin) that you prescribed for Mrs. Jones is no longer covered by her insurance; please change it to Basaglar (glargine insulin), which is covered and the new preferred formulation.”
- “Patient’s Xarelto, a direct oral anticoagulant, is no longer being covered by their insurance plan this year; please change them over to warfarin.”
- “Your prescription for Mr. Smith’s Valsartan is no longer valid; it was rejected when he attempted to fill it at the pharmacy. Please change to an alternate covered therapy.”
- “The mesalamine that your patient has been using for 20 years now has a $600 co-pay; please change her medication to something — anything — else.”
All very nicely worded, all very polite, and all completely ridiculous. This process highlights just one more example of how we have let ourselves be railroaded into being told how to take care of our patients.
I certainly understand that insurance companies are in this to make money, and that every year they renegotiate with the pharmaceutical companies. They save a nickel on each prescription when they change from Brand X over to Brand Y as their “preferred medication” in a particular class.
One of the patients this year for whom I had to change their insulin formulation, was changed from that very formulation to a different one last year. It had been changed again the year before.
This cannot help us take care of patients and does not lead to better care. This can only lead to more profit for insurance companies and pharmaceutical manufacturers. It’s just like the requirement that we get prior authorization for imaging scans that we think are clinically indicated. Or my being required to put in a referral to get my patient her annual mammogram, or get approval from their insurance company for them to see a dermatologist, podiatrist, ophthalmologist, or audiologist.
“Your patient is entitled to 30 visits with their physical therapist this year; please enter a new referral so that this can be processed by their insurance company.”
For whose benefit?
So much of this leads to the beginning-of-the-year bombardment that we all face: the onslaught of messages that really don’t help us take care of patients, that really don’t lead to better care, more collaboration, or improved communication. It is a shame on us that we have let this happen, that we continue to let this happen. This is the busywork that grinds us down, that bruises our souls, and it’s time we said no. Just, no.
I’m sure everyone reading this is going to say it’ll never work, that we’re battling a Goliath (or more than one) that we can never defeat, tilting at windmills, shouting into the wind. But wouldn’t it be cool if we all banded together, if we all agreed that this year, the insurance companies and the pharmaceutical companies needed to do what we told them to do, not the other way around? What if we said they had to accept the fact that we are looking out for our patients’ best interests? Maybe we can get our patients on board with this as well.
Perhaps we can stand as a unified front and demand that this small part of the healthcare system change. We can tell them there’s no need for these medication switches — the insulin, the anticoagulant, the blood pressure medicine, they are working just fine.
If we all stood up and said,
“This is not the right way to take care of human beings, not the way we would want to be taken care of, not the way we would want our grandmother to be treated or our children to be treated.”
Then maybe we can begin to move the needle, to bring about the change that needs to happen. So, let’s all, with one voice, say, “No. Just no.” And then let’s see what happens.
This does seem more common with the newer delivery systems like self-injectors. My sister-in-law uses insulin (maybe more than one type), new self-injector tech, and has trouble like this constantly. It seems like she is fighting with the pharmacy or the insurance constantly.
My meds are generic pills, and no problem, except for the opiate painkillers, which is a whole other can of worms over and above health providers and pharmacies.
Same here on generics which have co-pays for anything greater than a Tier one. Metoprolol all day.
I was busy gathering data for a Trust so Arizona does not get rich off of us. And also take care of my one son who is smart enough to be rich but other unavoidable issues have prevented him from getting there. I gave you the short answer. Here is the longer answer:
Americans spend large amounts of money on healthcare each year. Included in are high healthcare insurance premiums with high deductibles, and additional co-pays making up much of the spend. As an example, you will have to fulfill the pharma drug deductible limit paying undiscounted prices before your drug is discounted by insurance.
The thought is you would fulfill the limit sooner by doing so. Except in many cases, people never reach the deductible limit yearly and are stuck paying the full price. This is a change from years ago when you always received a discounted price. Many or most people do not hit the full deductible before insurance kicks-in now. I do not. The market economy fails when applied to healthcare
Commercial healthcare insurance has figured out ways to spread the rising costs of getting care. The out-of-pocket expenses spread amongst three areas of costs (above) are what is associated with health and wellness in the country.
It is possible to navigate the cost issues if one is without insurance. For example, systems like Goodrx allow steeply discounted prices on many drugs with very substantial differences among pharmacies. It is also possible to buy through Canadian agencies at steeply discounted prices. I don’t know how this might apply to insulin or chemo therapy treatments.
I know of a friend, for instance, who was prescribed Eliquis, an expensive blood thinner, and she learned that it was as available through Canada as through Medicare part D, at a similar price.