Some insurers insist that patients forgo generics and buy brand-name drugs

I have United Healthcare, and I have to say I&#x27;ve seen this happen to me as well. I&#x27;m on a long term maintenance medication, which is delivered by patch. I was on the generic in my previous health plan, so my new doctor prescribed the same generic.<p>I used the mail order pharmacy and they told me that a 90 day supply would cost $347. I asked why it was so much, and where my prescription benefits came in. They said they didn&#x27;t cover the generic, and I said well do you cover the name brand one? They said they did, but they couldn&#x27;t give it to me because my doctor had ordered the generic. If I ordered the name brand, it would be $100 for a 90 day supply, which is a huge difference.<p>I called my doctor, and got them to change the prescription. None of the people at United Healthcare were offering any of this information, and I basically had to pry it out of them to figure out why they were trying to gouge me. Also, this was their own private mail order pharmacy, so all the money was going to them as well.<p>Ask a lot of questions before paying a lot of money.

The big secret is that bio-equivalent and generic drugs sometimes aren&#x27;t effective!<p><a href="http:&#x2F;&#x2F;cmlnetwork.ca&#x2F;generic-imatinib-is-it-really-the-same&#x2F;" rel="nofollow">http:&#x2F;&#x2F;cmlnetwork.ca&#x2F;generic-imatinib-is-it-really-the-same&#x2F;</a><p><a href="http:&#x2F;&#x2F;cml-iq.com&#x2F;generic-gleevec-is-the-same-the-same&#x2F;" rel="nofollow">http:&#x2F;&#x2F;cml-iq.com&#x2F;generic-gleevec-is-the-same-the-same&#x2F;</a><p>Frustrating that the article doesn&#x27;t point that out. These new formulas do not need to prove they work, they just have to prove that their active ingredient is the same after the patent expires.

You guys have the most bonkers health system anyone could imagine. 1&#x2F;6 of your economy goes on &quot;health care&quot;, but most of that doesn&#x27;t actually contribute to your health, it gets skimmed off by insurers, drug companies, individual practitioners, hospitals and lawyers.<p>Sooner or later you are going to wake up and realise that a government-run single payer scheme is the only way to go.

I wonder if the guy in the article has considered buying his drug without insurance? In the case of the generic for Adderall XR it is about $70 with a GoodRx coupon at Walgreens, which is less than the $90 copay to get the brand drug with insurance.<p>Even if your insurance company lets you use generics, it is a good idea to take a look at GoodRx, and take a look at Walmart.<p>I&#x27;ve had generics where through my insurance my out of pocket was a $20 copay, but when I checked GoodRx there was a $12 coupon. I&#x27;ve had other generics, again with a $20 copay if I got them through insurance, where they were $4 at Walmart with no insurance or coupons.

I&#x27;ve been hit by this too. The scam is really simple:<p>Take the example in the article: Shire normally sells Adderall for $200. They offer to sell it to UHC for $50. The generic costs UHC $60. UHC takes the generic off the formulary and will only pay for Shire.<p>For the end user the out-of-pocket cost goes from $10-20 to $50 because brand medications are in the &quot;Premium&quot; category.<p>By saving $10 UHC sticks you with a $40 higher bill - literally 4x what they are saving.<p>Targeting this specific behavior is trivially easy: change the law to require insurers to cover generic or brand for any RX at the patient&#x27;s choice.

Interesting read of comments.<p>A head of R&amp;D at Advertising Agency decided that he couldn&#x27;t take any more of the lying and corruption that occurred in the advertising industry. so he went to work in R&amp;D in the Medical Technology Industries Arena.<p>Six months later he was back as head of R&amp;D at the advertising agency. When asked why he had come back since advertising was so corrupt, he told them that the advertising industry were little children compared to the standard corrupt practises occurring in every area in the medical arena.<p>He had delight in telling me the reaction of the advertising agency staff at his return.

I skimmed the article, and there is another force at play that benefits insurance companies.<p>Insurance companies have a federally mandated percentage of revenue that they must use towards the reimbursement of their policy holders&#x27; medical costs. In the past, this ratio was too low and they&#x27;re been slapped with stricter conditions. But Health Insurance is an industry where you can basically pass on your costs to your policy holders with near impunity (the current &quot;healthcare debate&quot; rarely discusses cost control in depth, and instead spends time on the correct level of cost sharing). And if your overall costs grow, then you can raise your overall revenue. And when your overall revenues grow, you have more money to pay your executives.<p>Consumers lose, everyone else in the healthcare value chain wins.

My sister had an acne breakout in her teen years and went on a brand-name hormone suppliment - it worked wonders. She went on the generic and only had problems - so far as I understand the situation the delivery mechanism is different across brands; though it&#x27;s <i>very</i> rarely a problem for most people. As always, it&#x27;s your health at stake - if you feel as though something is not working for you then switch.

Perhaps it&#x27;s the same as with medical services?<p>Note that providers won&#x27;t typically tell you the cost of a procedure unless you give them your insurance.<p>Don&#x27;t insurers have negotiated (lower) rates with providers? Also there&#x27;s typically a relatively large deductible.<p>I&#x27;m guessing that between the negotiated price and the deductible and the non-sense of the insurer choosing something against common sense there&#x27;s actually money to be made off the patient.<p>So if you&#x27;re charged $1000 for an MRI and have to co-pay 200 and the negotiated cost is $200 you actually end up paying 100% of the actual cost. You can redo the math with whatever number, but the point is the percentage you think you&#x27;re insured for is not real.<p>If insurer asks you to buy a 10x more expensive drug while they have a much smaller negotiated price, they may end up paying less or actually making money.

American healthcare is weird.<p>I pay £9.50 for all of my meds. The NHS decides which is the cheapest version of the drug I need. And that&#x27;s what I get.<p>It costs £9.50 regardless of the quantity, brand or anything else.

The mile high view of USA health care is if we can &quot;eliminate&quot; the poor, the old, the sick, in the long run, it will make our economy stronger. It seems to be doing it&#x27;s thing.<p>The life expectancy is coming down for the first time in decades and the stock market is at a record high. It&#x27;s a &quot;social darwinism&quot; thing. We&#x27;re a living lab to test the theory out.<p>That&#x27;s the mile high view. I&#x27;m not sure what the long term consequences are.<p>&gt; US life expectancy drops for first time in 22 years<p><a href="http:&#x2F;&#x2F;www.cnn.com&#x2F;2016&#x2F;12&#x2F;08&#x2F;health&#x2F;us-life-expectancy-down&#x2F;index.html" rel="nofollow">http:&#x2F;&#x2F;www.cnn.com&#x2F;2016&#x2F;12&#x2F;08&#x2F;health&#x2F;us-life-expectancy-down...</a>

My first software job out of college was working for a healthcare company. I worked in the Drug Comparison team (which consisted of 3 people) finding people ways to save on prescriptions by beating the system using software! Yay, helping the world and stuff.<p>Actually, we ended up selling out and building systems that benefited healthcare provider&#x27;s formulary plans. For example, not recommending generics, which was most of what we got paid 500k+ per contract to do.<p>We did do some amazing work on Medicare Part D stuff, tho. We saved some elderly people tons of money by algorithmically reccomending them the right drugs at cheaper cost.

Some of this insanity is covered nicely in the econlog podcast[1] on the book Drug Wars[2]. The NY Times always wants to throw all of the blame at insurers, but they are trying to save money. The generic system is a Kafakaesque set of regulations and processes.<p>[1] <a href="http:&#x2F;&#x2F;www.econtalk.org&#x2F;archives&#x2F;2017&#x2F;06&#x2F;robin_feldman_o.html" rel="nofollow">http:&#x2F;&#x2F;www.econtalk.org&#x2F;archives&#x2F;2017&#x2F;06&#x2F;robin_feldman_o.htm...</a><p>[2] <a href="https:&#x2F;&#x2F;www.amazon.com&#x2F;Drug-Wars-Pharma-Raises-Generics-ebook&#x2F;dp&#x2F;B071RP95DN&#x2F;" rel="nofollow">https:&#x2F;&#x2F;www.amazon.com&#x2F;Drug-Wars-Pharma-Raises-Generics-eboo...</a>

I wouldn&#x27;t be surprised if this was due to issues with some generics not being the equivalent. Concerta is a weird drug with the one generic actually being rebranded brand name. The other generics are not considered equivalent by the FDA but the last time I checked some pharmacy such as Walgreens carry the non equivalents. Apparently they are tied up in a court case.<p><a href="https:&#x2F;&#x2F;www.fda.gov&#x2F;Drugs&#x2F;DrugSafety&#x2F;ucm422568.htm" rel="nofollow">https:&#x2F;&#x2F;www.fda.gov&#x2F;Drugs&#x2F;DrugSafety&#x2F;ucm422568.htm</a>

So I work in advertising <i>specifically</i> focused on pharmaceutical brands. One of my client drugs has a problem where Pharmacists are dispensing as generic where their drug has a different Mechanism of Action and is only prescribed after the generic fails. Pharmacists can actually be incentivized in some cases to give the generic when the brand-name is written. Apparently they don&#x27;t even have to tell you that they&#x27;re switching it.<p>We have multiple clients who are undertaking &#x27;dispense as written&#x27; campaigns with healthcare professionals to offset that.<p>I&#x27;m certainly not saying that it is ALWAYS the case that a drug which vs. generic is the best choice. Sometimes they are literally the exact same molecule.<p>Sometimes though, you&#x27;re not getting the same level of care. Sometimes not even the same mechanism of action.<p>I imagine an insurance company&#x27;s position on that might be the offsetting of liability. If a pharmacist dispenses a generic when the brand-name is different and the treatment fails the insurance company bears the cost of that in the form of extended care. (and possibly other things)

I monitor my blood pressure pretty closely, and noticed when my blood pressure medication changed between generic manufacturers, one particular manufacturer was less effective, and my pressure went up 10-15%.

I just don&#x27;t understand medical care in the USA. Medical treatment seems enormously expensive, if you are not insured and you get ill, you die and yet getting insurance seems to be resisted (Obama-care).<p>Would someone be able to explain (or point to an existing layman&#x27;s explanation) how medical care works in the USA, the issues with insurance and strengths and weaknesses.

It&#x27;s just that drug makers cut deals with insurance companies. Drop competing generics from your formulary, and we&#x27;ll give you a good price for our brands. Or maybe on a basket of products. So you get more money, both by paying less for the drugs, and by charging patients more.

Yet another problem that can be solved by a single payer system that can negotiate reasonable prices and doesn&#x27;t need to profit off its members suffering and death. Get rid of the insurance companies and you get rid of this problem and a whole lot more.

This is a straightforward consequence of Obamacare that was predicted before the law even passed. The imposition of onerous cost ratio requirements means a company can make more money only by raising costs, not eliminating them.

This article left me confused about why this practice exists. It seems like it could only be because the insurance companies are getting some kind of kickback (maybe in the form of lower prices on drugs) in exchange for having these anti-generic rules, but I would think that would be illegal. Can someone who understands explain more clearly the situation?

Same thing for me. When I get refills I see whichever psych happens to be free that day and they always comment on how weird it is that my insurance requires the brand name. I always tell them that I assume the insurance company has cut a deal with Shire and it appears I was right.<p>But my copay for the name brand is only $20 so it never occurred to me to complain.

The insurers often have PBM contracts that incentivize them in filling specific drugs. This is the most likely reason <a href="https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Pharmacy_benefit_management" rel="nofollow">https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Pharmacy_benefit_management</a>

I have to take levothyroxine and my endocrinologist insists that I take a particular name brand. The amounts are in micrograms and the dosage varies across brands, and since various pharmacies use different generics, the only way to get consistency is through sticking with a particular brand.

I am sure others have had the issue where you shop around for free versions of prescriptions only to have the insurer tell you to sign up for 90 day supply with a cost. They seem rather insistent on it but there have been no repercussions for my ignoring them

I&#x27;m relatively new in Germany. As far as I can remember, the doctors always prescribe the generic drug, but I can&#x27;t verify because I never keep the prescriptions. Can someone confirm?

What&#x27;s the guarantee that branded drugs won&#x27;t have any side-effects. There&#x27;s none. and they&#x27;re pretty expensive too.

People will anyway.<p>You only needs the slightest derivation from one&#x27;s habit and it&#x27;s over.

Adderall XR and Metformin actually are better than the generic.

Even having health insurance is not enough to afford healthcare in America these days. The fragmentation of American Healthcare in to this S##tshow, whos only function is to gouge the consumer, is proof that the US needs single payer, like the rest of the world.