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Generic Advice

Scott Martin

AS A FAMILY MEDICINE physician associate, I frequently meet with patients early in the new year who are upset. The reason: They just learned their medications are no longer covered by their insurance or will cost significantly more than before. Many times, the insurance company will send them a letter providing other options to consider. I work with patients to find a generic substitute that isn’t as costly.

Several years ago, I had an elderly gentleman in our office one morning complaining that he was having difficulty urinating. This had been going on for a couple of weeks. While we were talking, I reviewed his medications and noticed that he had tamsulosin on the list. It’s used to treat an enlarged prostate.

I asked the gentleman if he’d been taking the tamsulosin. He said he quit taking it about three weeks before the onset of his symptoms. When I asked why, he told me that the refill was going to cost more than $200 at his retail pharmacy.

While we were talking, I looked up the cost of tamsulosin on GoodRx.com, the discount pharmacy site. I saw that the cash price for this medication at a grocery store pharmacy was $9.99 for 30 days.

The gentleman said $9.99 a month would work for him, so I printed the GoodRx.com coupon and gave it to him. Not all of my elderly patients are well-versed in using the internet or smartphone apps. They don’t know how to research the lowest-cost medications, so I frequently do the research for them and provide them with discount coupons for their prescriptions.

This encounter, and many others over the years, make me wonder why everything related to prescriptions and health care has to be so complicated. While there are many factors involved, a major one is the lack of price transparency by hospitals, pharmacies and insurance companies. It’s hard to comparison shop when drug prices are difficult to find or even unlisted.

Many patients are loyal to a certain major retail pharmacy that they’ve used for years. Unfortunately, when pricing drugs, many retail pharmacies charge a hefty premium for generic medications. Often, pharmacies can obtain a common generic for pennies, but then mark it up as they see fit. They usually aren’t able to do this as much with newer, branded medications.

Walmart came out with its $4 generic drug list a few years ago. That approach has since been mimicked by other pharmacies. With a few exceptions, the cost of many medications runs $4 for 30 days and $10 for a 90-day supply. Many patients are unaware that Walmart offers low-cost generics. In another significant savings, Medicare now pays for more commonly recommended vaccinations.

Many other drugs can be prohibitively expensive. Frequently, Medicare diabetic patients are on new, once-a-week injectable medications that cost $700 for three months. Patients with chronic obstructive pulmonary disease can be on inhalers that cost more than $400 a month.

Despite all of the creative advertising by pharmaceutical companies offering a discount card or coupon for many new medications, the majority of patients on Medicare don’t qualify. These advertised discounts only apply to patients with commercial insurance.

Adding to costs, many Medicare drug plans also have a coverage gap commonly referred to as the donut hole. In 2023, the donut hole begins after you and your drug plan have spent $4,660 on covered drugs and lasts until the cost of your prescription drugs reaches $7,400. While in the donut hole, a person will pay up to 25% of the retail price of a brand-name drug or generic drug.

Several years ago, I learned that pharmaceutical representatives can track the number of prescriptions that we write as health-care providers. Generally, they’re not very happy with me because I don’t prescribe many branded medications.

I try to use generics as much as possible. My goal is to be an advocate for the patient and not the pharmaceutical company. I prescribe medicines that I think are best for their health and their pocketbook.

I also educate patients to be aware of the difference between a drug being “covered” versus “paid for” by their insurance. Just because a medicine, procedure, lab test or vaccination may be covered doesn’t mean that it’s paid for in full.

Too often patients call our office upset after a lab test or vaccination because it wasn’t completely paid for by their insurance and they’ve received a surprise bill for, say, $200. I recommend that patients call their insurance company or pharmacy to find out the out-of-pocket cost before having anything done in a non-emergency medical setting.

Schaeffer Center researchers recently detailed that federal government and Medicare beneficiaries are overpaying for generic prescription medications. They determined that, “Medicare Part D stand-alone plans paid $2.6 billion more in 2018 for 184 common generic medications compared with prices for the same drugs available to cash-paying Costco members.”

Who benefits from the dysfunction of the health-care system? Among the big winners are the health insurance companies. This brings me to a topic that may raise your blood pressure: the compensation of health insurance CEOs. The chief executives of seven of the largest U.S. health insurance companies collectively earned more than $283 million in 2021.

It’s important to work with your health-care provider to receive the most appropriate medicine for your health needs without unnecessary cost. Be sure to ask if there’s a generic alternative to a branded medication that you’re prescribed. Then ask for the cash price at the pharmacy and compare that with the cost under your insurance plan.

Happily, there’s increasing competition in the prescription market, which can lead to lower prices. Providers getting into the generic medicine market include Amazon Pharmacy, Blueberry Pharmacy and CostPlus Drug Company. I hope such efforts will bring more transparency to all aspects of health care.

Scott Martin is a semi-retired family medicine physician associate (previously known as a physician assistant) and has been practicing medicine for the past 18 years. His previous career was in academia doing research and teaching at the University of Georgia. He and his wife enjoy traveling and spending time with family. Scott’s previous articles were On My Shoulders and Too Trusting.

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