When Insurance and Pharmacies Compromise Patient Care

generic drug

by Gary S. Litman, OD, FAAO

I practice full scope optometry with an emphasis on medical eye care. Since the beginning of 2014 and increasingly getting worse, I have experienced a growing number of denials for branded prescriptions. This has compromised my ability to treat patients with the most effective medications. I have been waiting for organized optometry to address this issue, but so far I have not observed any discussion.

I stay up-to-date on the newest and most effective treatments via medications and technology. On every front, we are seeing a push for optometrists to become more medically oriented. My concern is that insurers and pharmacies are preventing me from prescribing these new, more effective medications.

In recent months, in every category of ophthalmic drugs I E-Prescribe, I receive a significant number of denied branded drugs with a recommendation for generics or OTC drugs. I have observed on occasion, pharmacies substituting generics for branded drugs without my consent. I have observed patients who have the same insurance for the previous two years and have been taking specific branded drugs effectively get denials and a request for prior authorization. Most of these drug denials are

for allergy and glaucoma medications which are repetitive drugs. In the allergy category, a patient may be required to fail with Zaditor, Optivar or Elestat before a branded medication may be approved. In the glaucoma category, a pharmacy may request substitution of generic Xalatan or I have had patients return who are taking the generic Xalatan without my consent.

What is the difference between a generic drug and a branded drug? Pharmaceutical companies that produce branded drugs must submit many levels of clinical trials and go through rigorous drug testing via the Food and Drug Administration. A company that produces a generic submits an abbreviated form of the process. They do not have to establish a safety or efficacy profile because it has been established by the testing of the branded medication which has already been conducted. Generic companies only have to show bioequivalence to the branded drug. Bioequivalence is usually evaluated by the amount of the active ingredient that is released into the bloodstream at the same speed and concentration. Bioequivalence of ophthalmic drugs are not evaluated the same way as other drugs because they are applied topically to the eye and not into the bloodstream. Therefore, the generic criteria for ophthalmic drugs must have the same active ingredient with the same concentration as the branded drug, the same dosing and same route of administration. Without true bioequivalence for ophthalmic drugs, eye care providers have no way to be confident that they work equally as well.

The main difference in generics is the inactive ingredients and preservatives. Because insurance companies are constantly changing formularies, eye doctors are forced to switch to a generic drug instead of a branded drug. This requires a number of follow-up visits to check for the efficacy and tolerability of the generic. Generics may be produced by different manufacturers which would affect the efficacy of different generics. There may be an increase in allergy symptoms because of the different generic manufacturers and the ingredients they use. The increase in visits can offset the savings from the lower price of the generic.

I spoke to an insurance company executive who blamed the restrictive formularies on the pharmaceutical companies' high charges for branded medications. Yet most of the newer branded medications have significant rebates from the pharmaceutical companies. If the executive was correct, why are the pharmaceutical companies offering significant rebates to the insured population? If the drug is not on the formulary, the patient can establish themselves as a cash patient and use the rebate. By doing this, the pharmaceutical company's rebate reduces the fee for the branded drug significantly. Also, it is very obvious that insurance providers are saving significant health care costs by approving mostly generics and rejecting branded medications.

What We Can Do as Eye Care Providers

Always ask for a written denial from the pharmacy. In many cases, there is none. I have been told by many in the pharmaceutical industry that there are incentives for pharmacists to promote generic drugs versus branded with certain goals to achieve. If these goals are met, bonuses are rewarded. I believe that the insurance industry by issuing drug denials and requests for prior authorizations are anticipating that most doctors do not have the time for employees to spend all day on the phone.

On my IPAD, I have an app that can verify the coverage for a patient. This app is called Fingertip Formulary. This app allows the doctor to determine the drug status for different health plans. This app is sometimes not up to date.

Some websites that I have been using that can speed up the approval process are: www.rxhope.com and www.parxsolutions.com . I have used www.parxsolutions.com and have found it to be very helpful.

If doctors are experiencing the frustration of prescribing the most effective medications for their patients and receiving denials from the pharmacies, please share your experience and how you are dealing with this growing problem with The Optometric Society.

Gary Litman, O.D., F.A.A.O.
VP The Optometric Society