{"id":10915,"date":"2024-04-26T09:34:25","date_gmt":"2024-04-26T13:34:25","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=10915"},"modified":"2024-04-27T17:22:59","modified_gmt":"2024-04-27T21:22:59","slug":"hey-insurance-companies-and-pharmacies-stop-messing-around-with-cheap-generic-drugs","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/hey-insurance-companies-and-pharmacies-stop-messing-around-with-cheap-generic-drugs\/2024\/04\/26\/","title":{"rendered":"Hey, Insurance Companies and Pharmacies \u2014 Stop Messing Around with the Price of Cheap Generic Drugs"},"content":{"rendered":"
\"\"

Photo by Markus Winkler on Unsplash<\/p><\/div>\n

If you’re practicing medicine these days, you’ve likely experienced some version of this painfully annoying scenario.<\/p>\n

    \n
  1. You prescribe a generic medication, one that’s inexpensive.<\/li>\n
  2. Your patient goes to the pharmacy, and the pharmacist says that it requires a prior approval.<\/li>\n
  3. They leave without getting their meds.<\/li>\n<\/ol>\n

    Here’s a recent example from one of my patients (details changed to protect confidentiality):<\/p>\n

    A 74-year-old man goes to the emergency room with facial cellulitis. I am called by the emergency room clinician, who wants to prescribe cephalexin plus trimethoprim-sulfamethoxazole. (He said Keflex and Bactrim because he just can’t quit the trade names.)<\/em> I suggest linezolid, which has been available as a generic for years. A 10-day treatment course of linezolid is prescribed by the ER doc and sent electronically to his pharmacy. When my patient gets there \u2014 face all swollen, in pain \u2014 he is told that the prescription “requires a prior approval.” He leaves with nothing. The emergency room doctor is off their shift, so the patient’s daughter pages me to get the prior approval done.<\/p>\n

    Why is this insane? Because linezolid, which used to require prior approvals due to high cost, is now good value without<\/em> insurance coverage. Requiring a prior approval makes zero sense when you can get the generic for such low out-of-pocket costs.<\/p>\n

    GoodRx says that with one of their coupons, the price could be as low as around $35<\/a> for 10 days.<\/p>\n

    CostPlus drugs charges around the same for 15 days<\/a>, and they’ll mail it to you.<\/p>\n

    But you’ll note on the GoodRx site that there’s quite the range \u2014 the “retail prices” can be as high as $3500! And one of the big pharmacies still charges over $800.<\/p>\n

    These shenanigans have been going on for years with drugs far more commonly prescribed than linezolid. From a 2017 article<\/a> in The New York Times:<\/em><\/p>\n

    \n

    In an era when drug prices have ignited public outrage and insurers are requiring consumers to shoulder more of the costs, people are shocked to discover they can sometimes get better deals than their own insurers. Behind the seemingly simple act of buying a bottle of pills, a host of players \u2014 drug companies, pharmacies, insurers and pharmacy benefit managers \u2014 are taking a cut of the profits, even as consumers are left to fend for themselves, critics say.<\/p>\n<\/blockquote>\n

    Here’s what I think<\/em> is happening with linezolid, but who knows. The payers (or their henchmen the Pharmacy Benefit Managers) require a prior approval because linezolid used to be so expensive, and they haven’t updated their policy. And pharmacies (who may be owned by the same mega-company), try to get patients to use their insurance to get the higher price covered.<\/p>\n

    But this strategy can clearly be harmful to patients. And it’s dishonest almost to the point of being fraud.<\/p>\n

    I confess that I don’t know with 100% certainty why some payers and pharmacies require a prior approval for linezolid, but I very much do know what the ethical thing to do would be. The beleaguered, overworked frontline pharmacist \u2014 and I am very sympathetic to their plight!<\/a> \u2014 would, on seeing that an inexpensive generic drug requires a prior approval, say the following:<\/p>\n

    I’m sorry, Mr. Smith. Your insurance company says you need a prior approval for this drug before I can fill your prescription here. But if I were you, I’d ask your doctor to send a prescription to pharmacy X, Y, or Z, where they will give you the generic for way less money if you don’t use your insurance. For that matter, your out-of-pocket payments there may be even less than your co-pay if you fill your prescription here with your insurance.<\/p><\/blockquote>\n

    There are a lot of things to be proud of when you’re a U.S. citizen. But this crazy healthcare system we have sure isn’t one of them.<\/p>\n