Grrrr! Some doctors need a swift kick in the butt!

[hedgehog]

So, my BIL told my husband that their mother's latest prescription cost $1600 per month and wasn't covered. My husband asked a few questions, they called the insurance company and were told of an equivalent drug that will cost them $20!

[Warpy]

1. They definitely need to ask that doc why he prescribed the gold plated name brand drug

rather than an older generic drug. It would be interesting to hear him hem and haw about it.

ETA: always insist that they tick that "generic substitution" box unless it's something really critical like thyroid replacement.

[Downwinder]

2. Dollars to do-nuts:

You still are not getting the whole story.

[hedgehog]

3. Not getting the whole story - that goes without saying -

family dynamics can be very frustrating!

[Downwinder]

4. Medicare Part "D" dynamics I can understand

and if possible come out ahead. Family, no way, I'm out of here.

[cbayer]

5. I would be interested in what the insurance company deems an "equivalent drug".

I would also be interested in whether the person saying this is a medical professional.

A possible explanation is that the insurance company has disallowed this drug because of it's expense, but that it is the best choice for the patient.

Most doctors don't know what is or is not covered by the myriad of insurance companies that their patients enroll in. They are generally just interested in prescribing the best treatment.

[hedgehog]

6. I wish I had more details so I could make a better judgement.

I'm going by what my husband had to say on the subject; he's pretty savvy to this. He talked to the insurance company and looked up the drugs and judges that the cheaper drug is certainly worth at least discussing.

Sometimes you have drugs in the same class that work in different ways. Thus, Paxil, Prozac, Welbrutin etc. are all classified as anti-depressants. However, anyone who has been treated for depression can tell you that they are not interchangeable.

Sometimes you have an old drug that is going off-patent. The drug companies get around this by tweaking the formula or even just the delivery system and market it as ****NEW****. Sometimes it's worth the extra money to pay for an extended release dose. Sometimes you're just paying big money for a single pill that combines two inexpensive drugs.

I am dealing with several long-term chronic conditions myself. For some scripts, I have to have the name brand. For others the generic does just fine.

I guess the takeaway is that the patient has to be proactive and engaged.

[Sgent]

8. No insurance company I have seen

puts wellbutrin, effexor, or prozac in the same class. They are all antidepressents, but they work differently and on different parts of the brain.

There are definately indications for prescribing a SSRI over an SRNI (or the reverse), vs wellbutrin, etc.

Now, a better argument could be made that within a class -- Prozac vs. Paxil vs. Zoloft you may try different drugs, but I would be livid if the "insurance company" started practicing medicine.

[hedgehog]

9. Actually, my own insurance company suggested I make

a switch such as I described. It was a few years back, and they didn't insist.

Insurance companies practice medicine all the time. Just ask all the people who've had their request for surgery turned down!

Sometimes it's good to have a second opinion, but having the second opinion come from an entity with a financial interest isn't the best idea!

[SheilaT]

7. I expect that most doctors do not know

what most medications actually cost. Why should they? They are not the dispensing pharmacists.

Plus, as someone else has already pointed out, how can they possibly know how much of the cost your particular health insurance will cover?

In a similar way, our crazy way of paying for health care means that it can be difficult to know ahead of time what you'll actually be billed for some procedure you get in a doctor's office, at a lab of some kind, or at the hospital. Again, different insurance companies have negotiated very different payments for each and every procedure, and the person administering the procedure has nothing to do with the billing.

And the health insurance companies have absolutely no interest in making anything any easier for anyone. There is absolutely no reason, given computer technology at this point, why your insurance card can't just be swiped at the hospital, doctor's office, pharmacy, whatever, and what you have to pay will pop up immediately. But the insurance companies prefer to have everything as opaque as possible, and are really in the business of avoiding paying.