[LMB] Problems with Medications (was Worst Bujold villain)

Shalom Septimus druggist at pobox.com
Fri Apr 24 19:47:03 BST 2009

On Fri, 24 Apr 2009 07:22:04 -0700 (PDT), Elizabeth Holden
<azurite at rogers.com> wrote:

>Well, why not?  I don't understand the mechanism, or where the prohibition 
>comes from.  You say you 'have been changed' - by your doctor?  Who made the 
>change or the choices on the prescription?  Don't you have the option of 
>talking about it with him?  Or is this a legal dictum by the government?

The only person who has the legal authority to make any change in her
medication regimen is her doctor. That having been said, the insurer
telling the doctor "Change this drug to that one, or else we'll stop
paying for it", in a drug that costs $205.87 for 9 tablets (at least
in my store), is a powerful incentive for the doctor to make that

Since the insurance company is not the one actually writing the
prescription, they can then claim that they aren't practicing medicine
without a license, which is a serious offence, and also shields them
from malpractice suits (except in Texas, which specifically allows
such suits against insurers). 

(Can you tell I don't like Pharmacy Benefit Managers very much; they
claim to be saving money for insurance companies, but they do this by
taking it out of our (meaning pharmacists') pockets, and incidentally
lining their own. This is why some of the giant pharmacy chains have
started their own PBMs, or bought existing ones. Doesn't help much for
independents like me, but at least the money is staying within the
industry and not winding up in the pockets of parasites.)

Marilyn: Allowing four tablets per dispensing in a drug that comes in
a 9-tablet unit of use pack is insane. We don't break those if at all
possible, as what are we going to do with the other 5? Especially
since even if I fill it twice, I still have that last tablet left over
(because it's 9 to a pack, not 8) and the reimbursement on brand-name
drugs is so close to my cost that the last tablet may mean the
difference between profit and loss. Isn't there some way the doctor
can apply for a prior authorization to allow you to at least get one
whole pack at a time?

(grumblesnarf. I bet the insurance company execs don't have to worry
about stuff like this, oh no. Their plan probably covers every
medicine in the book.)

I don't know how many refills they allow per month or how many
migraines you get per month, but if you can get a few tablets in the
drawer before the headache starts, and make sure that you refill it as
soon as you use it, you might be able to keep on top of this. Can the
pharmacy mail you the tablets and save you the drive? Worse comes to
worst, if you can afford it, buy one pack for cash and store it. This
way you always have a cushion to fall back on.

Imitrex has a generic, but it's not that much cheaper than the brand
($192.31 vs $237.60 per nine tabs); hopefully once there are a few
more manufacturers on the table, the price will drop. Note however
that most pharmacies base retail cost on AWP, which on a drug with a
very expensive brand name product will stay very high even if the
acquisition cost is much lower. Try an independent pharmacy if there
are any left in your area; once the generics start to come down in
price you might be able to do a deal with him for a lower retail
price. You can't bargain with chain pharmacies.


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