Wednesday, July 25, 2012

Thank you, Zofran, Dilaudid, and Insurance Companies!

Zofran (ondansetron) blocks the actions of chemicals in the body that can trigger nausea and vomiting.
Zofran (ondansetron) blocks the actions of chemicals in the body that can trigger nausea and vomiting, typically in patients undergoing chemotherapy. I have had and continue to have the pleasure of taking this medication during my various medical procedures and undertakings. Ironically, one of Zofran's more pronounced side effects is its unique ability to trigger headaches. Since I have been a long term migraine and headache patient, I find this amusing. I have been on a cocktail of various pharmaceuticals for the last ten years or so with my fair share of interesting side effects. But more to the point, I was prescribed Zofran after chemotherapy medications to prevent or as an abortive medication for nausea and vomiting. Alas, it worked! However, the headache that followed was awful. Insert the conundrum:
Mixed within the various pharmaceutical cocktails that I have been taking over the last decade, there have been many powerful opioid painkillers prescribed to offset the chronic pain I was suffering and to offset the pain from various in and outpatient procedures. Now, since I was opioid naive, I did not tolerate these medications well at all. The opioid medications prescribed to relieve the pain I was in were now producing unwelcome and sudden nausea and vomiting. However, they provided much-needed pain relief and quality of life. My physician's solution? Increase the dosage of Zofran to offset the nausea and vomiting caused by the opioid painkillers. Seems fair right? Well, I obliged and increased the dosage and of the medication and as a corollary, the frequency and intensity of my headaches increased. I didn't see the big picture at first, so I simply increased my opioid medication to offset the headaches which then increased the nausea which increased the usage of Zofran. Such a wonderful cycle I had started.

When I finally realized the problem and cyclical nature of my nausea and headaches, I spoke to my physician again. We simply changed the opioid medication  to one I "may" tolerate better. I started my pain medication with Dilaudid on at 8mg dose by mouth. (If any physicians, pharmacists, nurses, pharmaceutical reps, or people with a working knowledge of Dilaudid and dosing instructions, this is the highest dose made in pill form in the United States... you may now pick up your jaw from the floor...) Since I was opioid naive, this was a VERY high dose of a power pain medication...but given the circumstances and general condition and outlook of my health, I suppose it was acceptable as it did relieve my pain and give me quality of life back. I did ask my physician, after not tolerating the 8mg tablets of Dilaudid well, if I could switch to a 2mg or 4mg tablet. He said he would have prescribed that, but since there was a nation-wide Dilaudid shortage, only 8mg tablets were available in our region and he suggested that I "split" or "halve" the tablets using a pill cutter. I didn't like this idea very much.

At the time, I didn't understand what a nation-wide shortage of a prescription drug or controlled substance was yet and it made little sense to me. In short, the pharmaceutical companies that create these drugs that are considered controlled substances by the US DEA, having a production quantity limit or ceiling for each calendar year. In the beginning of the year, the pharmaceutical companies submit their requests or estimates for the total number of a controlled substance that they are going to produce for that calendar year based on a number of factors. In mid to late 2011, for those who take Adderall as adults or purchase it for their children with ADD or ADHD, you may recall the nation-wide shortage and all the outraged parents because they couldn't control their hyperactive kids. It is estimated that the same Adderall shortage will continue and repeat itself again in 2012. Why you ask? Simple. Market demand exceeds that of permitted lawful production in the US by FDA and DEA regulations. In my case, it happened to Dilaudid and the generic form hydromorphone as well. Why you ask? See above. Except doctor's didn't start writing more Dilaudid prescriptions because it was a new miracle painkiller or the doctors had some sexy pharmaceutical rep in their office offering free complimentary incentive sample massages...er..pamphlets for the prescribing physicians. Quite simply, it was that it became a popular drug for patients or drug-seekers to abuse which jeopardized the supply and skyrocketed demand and pharmacies began dispensing the medication by the wheelbarrow. As such, patients like me could only acquire the dwindling supply of the higher dosages that most doc's usually don't dispense. The same thing happened with Adderall and/or the generic forms often called Amphetamine Salts in 2011 and again in 2012.

Al Capone Prosecuted under RICO ACT
Alphonse Gabriel "Al" Capone
I think I went a bit off topic there in terms of background, but after I became tired of the Dilaudid shortage and I tried several other CII opioid pain medications (that later also went into nationwide shortages coincidentally) and found a fair balance between Zofran and the pain medication.... Either that, or I simply became opioid tolerant, which is my personal opinion. Anyway, this is what brings me to my point and my  "salute" (sarcastic one, at best) to pharmaceutical companies and insurance companies for jacking up the prices of drugs and in all likelihood participating in some sort of price fixing that in ANY OTHER INDUSTRY would be prosecuted under the US Federal RICO Act. Yet, the pharmaceutical companies, pharmaceutical sales reps,  insurance, pharmacies, wholesalers, distributors, investors, pharmaceutical patent-holders, are exempt from this. Yes, I understand that research and development costs a lot of money and that pharmaceutical companies have a limited window of opportunity to recoup their monies from R&D before their patent expires and some third party can make a slight seemingly-innocuous change to the chemical makeup of the original drug and then market the "new" version of the original patented drug as a generic without spending anywhere near as much as the original patent holder/pharmaceutical company did when creating the drug. That doesn't seem fair but that's a story for another day. In addition, the original pharmaceutical has to recoup their monies spent on marketing their product. I can only imagine what those budgets are...

Ok, if you're still reading, you are probably wondering why I am giving you a brief education in the pharmaceutical industry and about RICO statues, collusion, price-fixing, and how another company can come along and make a minor change to your patent and re-brand your product as a "generic" and sell it for far less than the original patent-holder because the original pharmaceutical company did all the R&D and marketing...so now the new company comes along, makes a slight compound change, and CHA-CHING! Near instant profit... Especially since in a majority of states (I will use Massachusetts as an example here) require pharmacists to follow Drug Interchangeability & Midstream Interchange... Basically, it means that pharmacists are required to dispense a generic or less expensive medication to the patient unless the doctor specifically writes "DAW" (Dispense As Written) or "No Substitution" and that does not happen often, according to my pharmacist friends...
According to Massachusetts law, pharmacists must dispense a less expensive, reasonably available, interchangeable drug product provided that (a) the drug product is listed in the Massachusetts List of Interchangeable Drugs (MLID) and (b) the prescriber has not indicated "no substitution". A pharmacist shall interchange accordingly when dispensing a new prescription or a prescription refill presented after the effective date of interchangeability.
Former Valium Marketing Material To Doctors To Protect Brand Sales
 Insurance companies have a field day and deny deny deny when doctors write "DAW" or "No Substitution" because there is hardly ever a medical reason to do so. It just seems unfair to me that the original pharmaceutical company spent the money on R&D, marketing, FDA approvals, educating doctors, and trainings and some third party company can "tweak" the original formula and slap their generic label on it and sell it at a fraction of the cost while still making a profit. An example (left) of former marketing material sent to physicians encourages doctors and/or those licensed to prescribe to protect their practice and patients by ensuring that the pharmacy and pharmacist follow the explicit instructions from the prescription and not permit any substitutions: even by any comparable generics that act chemically the same but are produced by different companies. Perhaps if we did not have these ongoing price wars or patent wars, the prices of our prescription drugs would not be so astronomically high.

Anyway, this brings me to my point. My particular health insurance plan (considered one of those "Cadillac" health plans & not to be confused by the car) has a great prescription formulary list and covers a lot of drugs that a majority of companies do not. My co-pays are reasonable and deductibles non-existent. However, the company plan only permits 9 (nine) 8mg Ondansetron tablets per month. The company plan also only permits 4 (four) 8mg Zofran per month. As you probably guessed, Ondansetron is the generic form of Zofran which is patented and made in EU, UK, and USA by GlaxoSmithKline. Does this make sense to anyone?
  • An average chemotherapy patient will likely use more than 9 or 4 tablets of their anti-nausea medication during a month. These are figures I used from my health plan's formulary list 2011/2012 and quantity limit. 
  • My Health Insurance Plan does let me obtain more of the drug but I am required to pay additional co-pays:
    • My generic co-pay amount is $25 and my brand co-pay is $50
    • Thus, since I am prescribed 90 (ninety) 8mg Zofran a month and my pharmacist substitutes Ondansetron to "save" me money, my co-pay for this drug is $250 ($25 per 9 tabs multipled by 10 to account for the 90 tabs dispensed)...
    • If I were to have the Zofran dispensed in lieu of the generic, my co-pay would be $1,125 ($50 per 4 tabs multiplied by 22.5 to account for the 90 tabs dispensed)
  • After doing some research on pharmacy and drug prices in the US online, I found the following as of July 25, 2012:
    •  The average cost per pill for brand name Zofran 8mg was around $19 per pill cash. There were some sites and pharmacies that charged more and some less, but some appeared less reputable than others:
      • This means that the total (not accounting for any "discounts" or "negotiated rates" between the pharmacy and patient's insurance carrier) would be $1,710 for 90 (ninety tabs) of 8mg brand name Zofran and after you deduct my co-pay of $1,125, the insurance company pays the pharmacy $585 (again NOT including any discounts or negotiated rates with the insurance plan)
    • To further my point, the average cost per pill for generic Zofran, Ondansetron, was around $3.90 per pill cash. There were some sites and pharmacies that charged more and some less, but some appeared less reputable than others:
      • This means that the total (not accounting for any "discounts" or "negotiated rates" between the pharmacy and patient insurance carrier) would be about $351 for 90 (ninety tabs) of 8mg generic brand Zofran, Ondansetron, and after you deduct my co-pay of $250, the insurance company pays the pharmacy $101(again NOT including any discounts or negotiated rates with the insurance plan)...
      • And in my case, I saw the following on my receipt/paperwork that I think I was not supposed to get. 
        • Insurance Paid: $0.00
        • Customer Paid: $250.00
      •  So it appears that the pharmacy made money off me and the generic? Does this make sense to anyone? My other prescriptions that I picked up today that had co-pays of $25 said that the Insurance Paid "$87.43" or whatever the amount was in addition to the Customer Paid "$25.00"... 
        • So clearly for the generic Zofran, something is odd here. Do they have an incentive with the PBM or the wholesaler setup where the distributor is giving generous discounts out based on volume pricing or the manufacturer is giving the same discounts so transactions like mine above go STRAIGHT to the bottom-line as profit?
 I know I don't have the whole story here but something seems curious. I know my particular pharmacy is not trying to rip me off per se... The pharmacy I frequent is a non-profit community health center that provides health care and discount prescriptions to those that could not otherwise afford them. Perhaps this generic Zofran transaction helps their bottom line, but according to their financials they have a separate donation line item for these programs.

I also know that there are certain insurance contracts or rules and maybe perhaps regulations that prevent pharmacies from disclosing "cash" rates versus "insurance" rates. For example, I am prescribed a medication that is not on their formulary and it is considered a "medical food" and the whole prior authorization procedure is a giant pain in my ass. I am prescribed a 90 day supply 4 times a year and have to go through tons of paperwork, phone calls, and faxes to get this approved and quite frankly it's just not worth it. To get to the point, when I picked up the prescription the cashier or pharmacy tech did a "double take" at the register when the price came up. He stuttered and said, "Uhm.... that will be $350 Chris... I think?" He told me that was the "insurance rate" that my insurance company paid or reimbursed them but since my prior authorization had expired, had disappeared, or simply sprouted legs and walked off to the local CVS, I had to pay that price because the insurance would not approved it. I asked the cashier how much the "cash" price was. There was a long pause. After a minute or two he said he wasn't supposed to do this but removed my insurance information for this transaction and said the cash price was $200. Can someone in the health care industry explain this to me? It just doesn't make any sense. I'm an accountant... can someone explain this bizarro health care law or even how this makes financial sense to me? I bill my time out at $450 an hour and the last time I did the paperwork, phone calls, faxes, and doctors notes for the prior authorization procedure, I spent over 90 minutes of my own time over several days. You do that math. Not worth it...

All I know is this: From my perspective, my "Cadillac" insurance plan "jacked" up the price of a medicine that requires a prior authorization but if I did not have any insurance I could buy it for $150 less, not including my co-pay. Even if "Cadillac" Insurance Plan had paid for the medication, I'm sure there is no way they would have received $350.... They would be reimbursed a small percentage above cost plus a small fee for the computer processing time, label, and pill container (maybe $1.50 - $3.00) per prescription?

Sigh...

7 comments:

  1. This is BOGUS Chris! If you can afford your self-proclaimed Obama "CADILLAC ESCALADE" health insurance plan from God himself (a/k/a Obama) why are you complaining about a stupid $300 co-pay when the medicine costs thousands of dollars that you OBVIOUSLY could pay you cheap bastard! Quit complaining!

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  2. Dude why the hell do you need 90 Zofran? That is like $3200 to your insurance and you complain about $300 co-pay? When you are dying in hospice I hope you think back about this since no dount you will be on medicare or medicaid and my tax dollars will pay for your pain meds to put you down like the dog you are!

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  3. Yeah kid, cancer sux. Get over it. Atleast u have insurance and can pay for treatment and meds. My dad died as a Vet wit nothin and never got any of your fancy meds and got a $50 Vet funeral and was quickly forgotten at the VA hospital. He served his country proud. What did you do to deserve your "Caddy" insurance? You better than my pops? Doubt it you republican scumbag.

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  4. Dude back off. Those drug companies save lives and people thay can pay FULL price and drive an Obama Cadillac should pay full price because it makes it affordable for the other 99% that cannot afford those meds or insurance. Get real and walk a mile in my shoes you 1% elitest bastard. Good luck with your $250k+ a year income tax. I'll gladly take your tax dollars as my refund. PEACE!

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  5. I never claimed I was rich or affluent but I have been able to maintain my health insurance, which is paid for privately - not through an employer or discounted group plan. Without it, I would never be able to afford my medications, doctor visits, nor medical procedures.

    I was merely complaining that something didn't quite add up with my recent co-pay experience, especially given that the cost of generic drug I received was FAR less than the $200 or $250 co-pay I had to pay the pharmacy for a generic drug that costs them pennies on the dollar.

    As for the 90 Zofran? It was what the doctor prescribed. I think he thought it was making it easier for me to afford by providing a 90 seemingly 90-day supply so I would not have to pay 3x co-pays (1 for each month - 30 day supplies) but it backfired & clearly didn't work out that way. And do I need the Zofran? Maybe not. Does the Zofran help me deal with the effects of the other medications and treatments and give me a BETTER QUALITY of life, yes. It is worth every penny. I just think I should pay fairly and equitably, not just because of some insurance or pharmacy contract. Like I said, the cost per pill multiplied by the quantity dispensed was less than what I had to pay the pharmacy in co-pays.

    If you look up, for example, Ondansetron 8mg on Costco Pharmacy's website, you will see what I mean*:

    As of July 27, 2012:

    ONDANSETRON HCL 8 MG TABLET (DRL):
    30 Tablets: $17.22**
    60 Tablets: $25.85**
    90 Tablets: $33.67**

    ONDANSETRON ODT 8 MG TABLET (SAN):
    30 Tablets: $30.31**
    60 Tablets: $49.84**
    90 Tablets: $67.37**

    The difference in the pricing? Two different companies making generics for Zofran: Ondansetron HCL. The first one, "DRL" is an pharmaceutical company in India that produces the generic. The second and more expensive one, "SAN" is a global pharmaceutical company with offices in Princeton, NJ. Further research into their corporate structure show that they are a subsidiary corporation (or under the corporate umbrella) of Novartis. I'm not sure where their generic Ondansetron is produced...it may be in the US or it may be in one of their other global pharmaceutical labs... so it's difficult to say why they charge more than "DRL" from India even though both generics are equally as potent and appropriate for Zofran substitution.

    By my estimate, I overpaid by at least $216...if not more. If I had simply paid "cash" and went to Costco in lieu of using my insurance, I could have avoided the $250+ co-pay and simply paid $33.67 or $67.37 depending on the generic manufacturer. Sigh...

    *: http://www.costco.com/Pharmacy/DrugInfo.aspx?p=1&SearchTerm=ondansetron&Drug=ONDANSETRON - Accessed July 27, 2012 at 10:32 AM EST

    **: Prices are "cash" prices

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  6. Jim. Dear Chris Britt, Thank you for the infrormation about Zofran. You have helped me more than any other source. God Bless You.

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  7. I have Express Scripts Medicare....RXMeddi and I pay $1.30 for 90 pills...I wonder if Zofran is covered???

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