Friday, March 28, 2008

Brand Medically Neccessary

(I read Pharmacy Chick's latest post and thought I'd like to put my own 2-cents in on this topic).

I believe that a prescriber should only be able to write for Brand Medically Neccessary if the patient has tried every single other option, and the doctor thoroughly documents how the generic was either ineffective or not tolerated. Basically, every single Brand Medically Neccessary script should require Prior Authorization, and insurance companies should strictly enforce this.

I'm sick of this brand name bullshit. Zocor is simvastatin; Norvasic is amlodipine; Toprol XL is metoprolol succinate. There's no fucking difference between the brand name and the generic except perhaps a little extra filler in one tablet. Hell, 1/2 the time, the generic is made by the same company that makes the brand name. There's almost no possible way a brand name could work any better than an AB rated generic. The only possible excuse I can think of is that someone could be allergic to certain dyes and therefore, requires the brand name that doesn't contain these dyes. Of course, the patient could probably switch to another generic manufacturer and accomplish the same thing.

I don't think doctors should be able to write Brand Medically Neccessary simply because the patient is some old lady who won't touch anything generic. I can't even count how many times I've seen absurdity like this: Lipitor, Brand Medically Neccessary. Uhhhh.... There is no generic for Lipitor yet. How do you know the brand name is medically neccessary if the patient has never even tried the generic? I actually think doctors should be reported for writing scripts like that. Basically, it's insurance fraud.

In my world a patient would not only have to fail a trial of a generic drug, but they'd have to exhaust almost every other clinically equivalent generic option in the same drug class. For example, if a patient fails pantoprazole, they'd have to also fail omeprazole before Protonix would be covered under the insurance.

If the patient truly needs the brand name, then he is entitled to it. However, all other options have to be exhausted and the therepeutic failure must be well documented. I guarantee that if a rule like this was enforced, you'd see a whole lot fewer Brand Medically Neccessary prescriptions, and the effect it would have is to lower the cost for patients, insurance companies, and increase the reimbursements to pharmacies. It's a win for every involved.


Death of Houseplants said...

The Synthroid/Levoxyl or Coumadin being brand necessary don't make me as mad as say requesting a brand name Z-Pak, or requesting the brand name drug when the doctor wrote the generic name on the prescription.

Pharmacy Mike said...

Synthroid, Coumadin, and Dilantin are exceptions because changing from Brand to generic can make a clinical difference in a patient.

However, if a patient has never had these drugs before, they should be mandated to start with generics.

Anonymous said...

I agree. Most people are delighted to get the generic, but when someone demands brand name (aka "the real thing")and it goes through, I always get a kick out of ringing them up for that whoppin' brand name copay -- just to see the Whaaaaa??
expression on their face. Like, NOW you get it.......

Carol said...

If they haven't tried the other brands and don't have a food or dye allergy that precludes all the others, then they should payt he difference is noct out of their own damn pocket.

Anonymous said...

I work near Delaware, so we have a bunch of patients who work at Astra Zenica. AZ brand drugs are free for them. For obvious reasons, I have no problem with them requesting the brand. It annoys me though that they get their docs to write them as brand MEDICALLY necessary. Clearly they are not medically necessary, they are financially necessary.

Pharmacy chick said...

Mike, nice post, and you have my vote. In my perfect world, If somebody wants brand where a generic is available--(narrow theraputic index drugs excluded)I wouldn't care if they have brand, but they pay 100% Cash, no discounts from their insurance.
None of this under-cost crap.

The Ole' Apothecary said...

Me, too. Coumadin, Synthroid, and Dilantin are my three that make sense for BMN. Some years ago, I filled RXs from a nephrology practice that insisted upon my filling only the Deltasone or Meticorten brands of prednisone. Nope, never read about exactly what was bum about other prednisone brands, but I respected these doctors' experience.

Anonymous said...

Eh. I take Wellbutrin and the generic not only doesn't work, but it makes my depression even worse. I shouldn't have to switch from med to med to med. My employer and I pay a lot for insurance that I barely ever use. I'd much rather pay the $10 generic co-pay than the $90 co-pay for the brand name, but if it doesn't work it doesn't work.

All generics are not created equal.

Pharmacy Mike said...

I don't know if you'll read this comment, but I wanted to follow up on what the previous anonymous poster just said.

Wellbutrin is actually one of those drugs that is a little different from all the others. It's not an SSRI. It's not an NSRI. It has properties of both as well as dopaminergic properties. It's sort of unique.

Therefore, if the generic really did not work after an adequate trial (which would be at least 2 to 4 weeks because that's how long those drugs take before there's a clinical effect), then the doctor would submit paperwork showing the therapeutic failure of bupropion to the insurance company, and you'd have your Brand Medically Neccessary Wellbutrin.

I'm telling you... If you had a group of pharmacists sit down together and outline which drugs in which categories can be considered therapeutically equivalent, this plan would work.

The main goal of it is to stop the frivolous writing of Brand Medically Neccessary on scripts simply because the patient does not want to take the generic. In maybe 1 patient out of every 100 (probably even a lower percentage), a generic will not work as well as the brand.

I'm just sick of hearing things like, "This Metoprolol XL does not work as well as my Toprol because it makes me dizzy."

Anonymous said...

I agree with you Mike – I realize this post is rather late but I felt compelled to comment. (I will apologize in advance for the extremely long post but I gave all of the comments a lot of thought and hope my input will be helpful) I am a huge supporter of generic drugs and prefer to get them over a brand any day. However, most people don’t understand the dynamics of the drug companies gouging the public – and the fact that pharmacy costs are a main reason for premiums to go up on a regular basis. I actually work for an insurer (HMO, PPO, CPPO, Workers Comp, Life, Medicare, and Medicaid etc.) and see things clearly from the cost / risk perspective. However – I do have a huge problem with insurance companies regulating drugs for psychiatric conditions. I am sure you are aware that people with true psychological conditions are terrible about taking their medication and if they are taking the brand then for God’s sake if they are clinically stable leave their medication alone.
Furthermore, brand psychiatric drugs (i.e.) Wellbutrin) are notorious for being extremely expensive so the following scenario emerges. A clinically depressed person cannot afford the higher copay / cost sharing for the brand, and stay on the generic even though their depression worsens (or they perceive it does) and they commit suicide, or take out their coworkers or classmates and then kill themselves. To me it would be less expensive for an insurance company to pay the cost for the brand and charge minimal copay than pay for the lawsuit of the grieving loved ones for the person or the people they killed.
While I totally agree with your standpoint that generics are the best option, I believe that the generalizations you have applied are belaying your obvious intelligence and informed observations. The generalization: “There's no fucking difference between the brand name and the generic except perhaps a little extra filler in one tablet.” gives the impression that you are incapable of empathy and understanding the basics of chemistry. I have pharmacist friends – I know the grueling chemistry classes that are necessary for that kind of professional degree so I am saying that with full knowledge that you are highly skilled and knowledgeable, but you are not doing your education credit by making such statements. Every person is unique and their own body chemistry is a factor in drug efficacy and tolerance.
Don’t get me wrong – I think there is a lot of abuse in the pharmaceutical arena – but I would say that average people are the victims of the shameless, irresponsible and unavoidable ads that promote brand drug preference. The average person is scared and uninformed and we should, as professionals, urge them to educate themselves, not loose empathy for them. If the pharmacy companies wouldn’t have shameless abandon to spend money on having every other page in Time magazine supporting their brand name brain washing we wouldn’t even have to have this conversation because medication would be less ‘big business’ and more research and humanitarianism. There is just no excuse for something ‘therapeutically equivalent’ to have such a vast cost difference other than greed. Just think if the drug companies put the millions they spend on commercials that run during the superbowl into research and development for diseases such as Diabetes, Cancer and AIDS we might be in a better position to fight them. I am not trying to make anyone feel bad… I am simply trying to refocus people’s attention on the real problem - the pharmaceutical industry.