Affording Medications

Another family called this week to ask if I could change their daughter’s asthma prescription to something cheaper. After looking into their insurance plan’s formulary, there really wasn’t anything cheaper. Every inhaled corticosteroid (which is the first-line medicine recommended to prevent asthma attacks) was expensive – even the generics. This family has to either find a less expensive way to purchase the prescription, choose to leave their child undermedicated, or pay over $300 per month for an asthma preventative medicine. Of course if they don’t give this medicine they risk ending up in the ER in the middle of the night. ER’s are expensive and if it’s a needed trip, it means their child is suffering.

Insurance companies make it hard.

On one hand insurance companies want patients to take the medicine appropriately to decrease long term costs of disease management. They even remind doctors to consider certain medicines if a patient has certain diagnoses and prescriptions haven’t been filled or if follow up appointments haven’t occurred.

On the other hand, they’re pricing many medicines out of reach for many families.

Transparency is a goal for healthcare, but it isn’t there, as Dr. Melissa Welby explains.

What can you do?

Check your formulary

When shopping for new insurance look at the formulary if anyone in your family is on a chronic medication. You will have to talk to an insurance company representative since formularies aren’t publicly displayed anywhere and they’re specific to your plan. This isn’t foolproof because formularies change on a regular basis, but at least learn what they currently have and what your costs would be.

Before doctor visits where you know you’ll be getting refills, check your formulary to see if it has any changes. You can usually log into your insurance company’s website to see your plan’s information.

See if you qualify for Patient Assistance Programs.

These are programs run by drug companies and other organizations that give free medicine to people who can’t afford to pay for them.

You can learn more about these on NeedyMeds, Partnership for Prescription Assistance and RxAssist.

You can also do an online search for “patient assistance program” along with the medicine name.

Shop around.

Look at GoodRx and WeRx to search local pharmacy cash pricing with their coupons. This doesn’t give the cost that your insurance will allow, but you can see how much it would cost with cash and compare to insurance cost. Sometimes it’s cheaper to not use insurance but see if the coupon will work with your insurance and compare costs.

Look at your insurance plan to see which pharmacy they prefer. I’ve had issues with this myself and I’m not sure if this is always helpful.

Get a Drug Discount Card or Coupon.

These can be used by anyone regardless of income or insurance plan. See MoneyCrashers for a nice summary on how discount cards work and when to use them.

You often can’t use insurance when you use the discount card, so you have to look at your deductible and calculate if it’s better to pay more until you meet your deductible and then get things inexpensively/free or if saving the money but not contributing to your deductible is better.

These cards can be used to help buy over the counter medicines (with a prescription) as well as prescription medicines. I think you can even get cards for your pet prescriptions.

To find drug discount cards, look at NeedyMeds, RxAssist, GoodRx, WeRx or the drug company’s website. I find it easiest to search the drug name and coupon together when looking for discounts.

I have a love-hate relationship with discount cards.

If people can’t otherwise afford a prescription (name brand or generic) then a coupon might help them purchase a needed medicine, but we all pay in the end.

Coupons are offered by manufacturers because they increase the sales of brand-name drugs by 60% or more by reducing generic sales. These programs increase drug spending by $30 million to $120 million per drug (and this study is several years old- coupons are increasingly being used so this might underestimate current spending).

Coupons can help people afford medicines, at least temporarily, but they increase insurance costs overall. If you use your insurance plan with the coupon, your insurance company pays more than they would if you purchased a generic, and they pass that cost on to consumers.

The money you spend doesn’t apply to your deductible if you don’t use insurance – and insurance companies then get off without having to pay for your medicines despite the fact that you pay them monthly to help cover your healthcare. I guess the good news is that if you don’t use insurance it doesn’t increase next year’s premium… but they might see you as “high risk” if you don’t fill recommended prescriptions, so that still might affect costs in the end.

Talk to your doctor.

Of course, it all starts with the prescription itself.

When your doctor is writing the prescription, openly discuss cost concerns, such as name brand vs generic substitutions in the same class of medications that might be available.

We cannot know your specific formulary, but we can try to help you find the cheapest option. Electronic Health Records sometimes link to insurance formulary information to give an idea of which tier a medication is on. I find this works some of the time. Sometimes it isn’t accurate. People still get to the pharmacy and suffer from sticker shock when they’re told the cost. This is why I think it’s so very helpful if you find your formulary before even going to your appointment. It can save a lot of back and forth at the pharmacy if we have the costs at the appointment.

If you get to the pharmacy and cannot afford the medicine, be sure to let your doctor know! We want to help but we can’t if we don’t know the issues.



Share Quest for Health

Cold and Flu Season is Upon Us!

Every year at this time, I think about how our kids are managed when they become sick. Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care. During cold and flu season kids get sick. A lot.

We are a busy society. We want things done now. Quickly. Cheaply. Correctly. Resolution so we can get back to life.

Illness doesn’t work that way.

Most childhood illnesses are viruses and they take a few weeks to resolve. There’s no magic medicine that will make it better.

  • Please don’t ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.
  • Don’t ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.
  • Don’t ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.
  • Antibiotics simply don’t work for viruses. They also carry risks, which are not worth taking when the antibiotic isn’t needed in the first place.

Urgent cares are popular because they’re convenient.

Convenient isn’t always the best choice. Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours. I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?

Can it hurt?

Extra tests = Extra costs

Some kids will get unnecessary tests, x-rays, and treatments at urgent cares and emergency rooms that don’t have a reliable means of follow up. They attempt to decrease risk often by erring with over treating.

The primary care office does have the ability to follow up with you in the near future, so we don’t have to over treat.

No history

Urgent cares outside of your primary care office don’t have a child’s history available.

They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).

It’s easy to fail to recognize if your child doesn’t have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.

We know that parents can and should tell all providers these things, but the new patient information sheets in my office are often erroneous when compared to the transferred records from the previous physician. Parents don’t think about the wheezing history or the surgery 5 years ago every visit.

It’s so important to have old records!

Records in one place

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.

Is it time for further evaluation of immune issues?

When should you consider ear tubes or a tonsillectomy?

If we don’t have proper documentation, these issues might have a delay of recognition.

Not all locations are good with kids

Urgent cares and ERs are not always designed for kids.

I’m not talking about cute pictures or smaller exam tables.

I’m talking about the experience of the provider. If they are trained mostly to treat adults, they might be less comfortable with kids.

They might order extra labs or x-rays that a pediatric trained physician would not feel are necessary.

This increases cost as well as risk to your child.

Drug choice and dosing can be complicated for clinicians not familiar with pediatric care.

We have been fortunate in my area to have many urgent cares available after hours that are designed specifically for kids, which does help. But this is sometimes for convenience, not for the best medical care.

Cost

As previously mentioned, cost is a factor.

I hate to bring money into the equation when it comes to the health of your child, but it is important, especially with the increasing rates of high deductible health insurance – you will feel the burden of cost.

Healthcare spending is spiraling out of control.

Urgent cares and ERs usually charge more.

This cost is increasingly being passed on to consumers. Your copay is probably higher outside the medical home. The percentage of the visit you must pay is often higher. If you pay out of pocket until your deductible is met, this can be a substantial difference in cost. (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about the walk in clinic at your primary care office? 

Many pediatric offices offer walk in urgent care as a convenience for parents who are worried about their acutely ill child.

If your doctor offers this, the care given is within the medical home, which allows access to your child’s chart. All treatments are within your child’s medical record so it is complete.

Staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols the group has agreed upon. Essentially primary care pediatricians have a high standard of care and want your child to receive that great care in the medical home as often as possible.

Telehealth

There are more and more telehealth options offered by insurance companies and physicians. This is a new area that has exciting potentials, but I’m concerned about inappropriate treatments. It can be a great tool to follow up on ongoing issues, but is not appropriate for many routine earaches, sore throats, and other issues that require an exam and/or testing.

I know it’s tempting to call in to get a prescription for a presumed ear infection or Strep throat, but think about how those diagnoses are made and remember that overuse of antibiotics increases risks to your child.

So what kinds of issues are appropriate for various types of visits?

(Note: I can’t list every medical problem, parental decisions must be made for individual situations. For a great review of how to determine if it’s an emergency, see Reliable keys to identify a medical emergency from Dr. Oglesby at Watercress Words.)

After hours (urgent care or ER- preferably one for children):

  • Difficulty breathing (not just noisy congestion or cough but increased work of breathing)
  • Dehydration
  • Injury (including but not limited to bleeding that won’t stop, a wound that gapes open, obvious or suspected broken bone)
  • Pain that is not controlled with over the counter medicines
  • Severe abdominal pain
  • Fever >100.4 rectally if under 3 months of age or underimmunized. (There is no magic temperature we “worry more” if an older child is vaccinated.)

Walk in clinic (or appointment) at your primary care provider’s office:

Being sick isn’t fun, but sometimes it just takes time to get better while using at home treatments. Use the healthcare system wisely to get the best care.
  • Fever
  • Earache
  • Fussiness
  • Cough
  • Sore throat
  • Vomiting and/or diarrhea
  • Any new illness

Issues better addressed with an Appointment in the Medical Home:

  • Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  • Chronic (long term) concerns (growth, constipation, acne, headaches)
  • Behavioral issues or concerns
  • Well visits and sports physicals (insurance counts these as the same, and limits to once per year so plan accordingly)
  • Immunizations – ideally done at medical home so records remain complete

telehealth

  • If your primary doctor (or specialist) uses telemedicine as part of follow up care this can be a great use of telehealth.
  • Be careful of “free” or inexpensive telehealth options from other groups, including those from your insurance company. A quick and easy fix isn’t necessarily a safe, effective, or needed treatment.
Getting appropriate health care is important. If you aren’t sure what the best plan of action is, call your doctor’s office.
 

Generics for Concerta 2017

Concerta is a long acting methylphenidate used to treat ADHD successfully in many kids and adults. It has a unique time release system that makes it preferred over other medications and difficult to recreate. Sadly, there are once again companies that are trying to substitute for Concerta. Generics for Concerta may not be equivalent to the real thing.

Deja vu.

I feel like I’ve been through this before.

Two of my most-read blogs (from my old blog) were about generic forms of Concerta available in 2013-14.

The FDA had allowed companies to manufacture and sell tablets that were not the same as Concerta. People across the country noticed the change immediately.

I started seeing patients who had been well controlled on Concerta for a long time who suddenly were not able to focus, were more angry, and had other focus and behavior problems.

No advance warning

Initially I had no idea there was a new generic, but one mother sent me a picture of the new pill and I knew instantly it could not be the same.

One more time

Now there are new generics from Trigen LaboratoriesMylan and Impax Laboratories that do not use the special delivery system of Concerta once again.

****New March 23, 2018: A patient sent this photo of their generic methylphenidate ER.

methylphenidate ER

I’m worried because it took many many months of people filing reports with the FDA through MedWatch before the FDA finally stopped allowing the substitution.

I hope the newly approved versions work better than the previous editions, but am worried not only because they don’t use OROS technology, but there are several new versions coming to market and each could be different.

Original generic rumors

I have heard that the previously available OROS generic (made in the same factory as the name brand Concerta and the same exact pill but with a different label) will no longer be available.

If this is true, options will be to pay for the name brand or go with a new version of the medicine.

What makes Concerta unique?

Concerta is the branded formulation of methylphenidate HCl Extended Release that has a unique time release system.

This time release technology is called OROS (osmotic controlled release oral delivery system).

Unlike many slow releasing medications that are released as the capsule parts dissolve, the OROS capsule doesn’t dissolve.

There is a little active medicine that is released immediately and then the medicine is slowly released through a small hole in one end of the capsule.

You can tell if you have the OROS tablets if they have a small dimple in one end:

 

The small circles on one end allow medicine to escape from the capsule.

The pill works like a pump, pulling in water from the intestines, pushing the medicine out of the tube slowly throughout the day. This allows for a consistent drug release. See this photo from Medscape:

The new generics

The same active ingredient (methylphenidate) is used in the new pills. I have heard that at least one version of the pills is round, so I know they don’t use the OROS system.

The package inserts do not specify what type of delayed release they will use.

I find it very frustrating that each of the package inserts (Trigen, Impax) appear to be nearly identical to the one for Concerta (including the initial US approval date of 2000, which is not correct for this form).

Older warnings, including a contraindication in those with tics, has been found in newer studies to not be a contraindication.

The fact that they did not push to remove it makes me wonder if they did not want to have to change other parts of the document. Figure 1 and Table 6 are identical with the exception of changing the word “CONCERTA” to “methylphenidate hydrochloride extended-release” and Trigen added an easy-to-read table format.

This makes me wonder if they were somehow able to get permission to make their new tablets based on Concerta’s data, not their own.

We’ll see how it works in people who have previously taken OROS methylphenidate ER. Sadly, one version might work better than another, so you will have to keep track of which brand you are using.

What’s good about the new generics?

Cost

If it’s true that the currently available generic OROS form of methylphenidate ER is no longer going to be available, it’s good that there will be other options to help keep costs down.

Maybe.

Sometimes insurance companies prefer branded products. It’s all how they contract the cost.

If you don’t know how to use your insurance company’s prescription formulary, you should learn. Also check out GoodRx for pricing information.

Will it work?

One might work as well (or better) than the OROS formulation in any individual. You won’t know until you try it.

One benefit I am excited about if these work: 

The Trigen version is available as a 72 mg tablet.

The original Concerta is not able to be made at that strength. You can see from the photos above that the pills get bigger with increasing dosages, and the OROS system has limits to how much it can hold.

For people who need 72 mg, they must take two of the 36 mg OROS tablets. Since patients pay by the pill and they need 60 pills/month instead of 30, this can be quite a bit more expensive.

What should you do if the pills change

Check each bottle when you pick up new medicine and ask if you can return unused tablets if they don’t work for any reason.

Keep track of what each pill looks like and the brand (which should be on the label) so you know which versions work and which don’t.

Talk to your kids about how they think and feel on and off their medicine – some will be more in tune with themselves than others.

Keep in touch with teachers as the pills change so you know if there are school-related issues you’re not seeing at home.

If the pills don’t work or have new or worsening side effects:

Talk to your HR representative who deals with the insurance company.

Call your insurance company directly. Send them e-mails and snail mail.

Ask your physician to write a letter on your behalf.

In each of the above situations, include why your family member needs the OROS technology. Give examples of how it works better than the other extended release methylphenidates and why the amphetamine class of medication failed (if tried).

Medwatch

People were able to get the FDA to look into the issue the last time a different tablet was substituted by submitting complaints to MedWatch.

It took a long time, but the FDA finally agreed that there are significant differences and the other substitutions were no longer allowed.

It’s easy and free. Please submit to MedWatch if you have any concerns!

Know your insurance formulary

If you need to change medications because the new generics don’t work well, it helps to know what other medicines are in the same class so you can look up your formulary coverage.

The ADHD Medication Guide has an easy-to-read format of ADHD medicines. Just look for other medicines in the same colored box as Concerta to find similar drugs.

To limit plagiarism of this wonderful chart, you must click on the user agreement in the center of the page. It is free and easy.

Medications have been arranged on the card for ease of display and comparison, but dosing equivalence cannot be assumed.

Talk with your doctor about what medicines will be best for your child (or yourself).

*The ADHD Medication Guide was created by Dr. Andrew Adesman of the North Shore-LIJ Health System.

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