Sunday, June 15, 2014

Is My Medicine on the Prescription Drug Formulary?

One of the frustrating aspects of medical practice is trying to divine if the medication I am prescribing is covered by the patient’s insurance company.  Even with the advent of electronic medical records, which should be able to determine this, we are often left to hope and pray.

Here’s how it works.  Individual insurance companies have formularies – lists of approved drugs – that they encourage patients and their physicians to use.  Of course, this is all about the money.  There’s nothing evil about an insurance company making a deal with a particular drug company that gives them a price break.  The drug company will be delighted to offer the insurance company a discount in return for an anticipated high volume of prescriptions.   You can easily picture an insurance company negotiating with several different GERD medication representatives watching them each lowering their bid trying to get the contract.  

Nexium Guy:   We’ll only charge you $.67 a pill
Prevacid Gal:  We’ll only charge you $.84 a pill and will throw in the Japanese steak knives
Protonix Guy:  We’ll lower our already rock bottom price down to $.65 a pill for an exclusive contract
Prilosec Gal:  We’ll only charge $.57 a pill for a brief term of 10 years with an option to renew

When a patient sees me for heartburn, and I recommend a medication to ease their pain, often neither the patient nor I know which of the 6 proton pump inhibitor medicines (e.g. Nexium, Prilosec, etc.) or the generics will be covered.   That’s when the guessing starts.  My objective, of course, is that the patient pays the least amount of money without sacrificing medical benefit.   When I guess wrong, I am then welcomed by phone calls, faxes and other forms of denial that we then devote time to sort out.  Recently, I called a pharmacist with the patient seated before me to try to be a hero and figure out which medicine was the right stuff.  Even the pharmacist couldn’t figure it out.  She explained to me that she couldn’t price the medicine for this specific patient unless I prescribed it officially and she then processed it through.   I thanked her, hung up and resorted to my default strategy.  I guessed.

Which Medicine?  Roll the Dice!

Keep in mind that these formularies change yearly.  In other words, a medicine that’s preferred  in December may be tossed aside in January when a new drug underbids them.  This adds to the adventure.  We have an office pool every December when we offer prizes for guessing the new medication changes.  We use this changeover as an opportunity to increase staff morale.  

Next time you're in your doctor's office, ask what a 'prior auth' is.   

In my practice, I might see 15 or 20 folks each week who want me to put their GERD fires out.  They have different insurance plans with different formularies and different restrictions.  The chance that I prescribe the preferred medicine to each of them on the first try is much lower than winning the lottery.  If fact, if I were to achieve this pharmaceutical tour de force, I think I am entitled to instant wealth.  Perhaps, the pharmaceutical companies would pool their resources an sponsor a contest for gastroenterologists.  What a slick marketing campaign!

Prescribe Heartburn Medicines Correctly for a Week and Win a Million Dollars!

They have nothing to fear.    While physicians may accept the challenge with enthusiasm, they will never succeed.  They would do better buying a lottery ticket. 


  1. What we need in our electronic prescribing is an additional button to accompany the "generic acceptable" button which could read "therapeutic equivalent". That way, if you write for one PPI and the patient's insurer covers a different and therapeutically equivalent drug, your office does not have to handle the prescription again, and again, and again...

  2. @MC, nice to have you back. Of course, your suggestion makes sense which is why I suspect it's a non-starter.

  3. You might want to set up your own dispensary in your office! Then if the insurance plan does not cover one PPI you may have the other one on hand! Guess what? You then get paid for your Rx time. What a great idea! I have done this for a 50 MD gastro and could set it up for you.

  4. By the way, with your own dispensary you eliminate the need for the "generic acceptable" button and rehandling scripts. You are directly tied in to most payers just like the chain pharmacies and since all meds are pre-packaged you do not need a pharmacist on staff. Besides the revenue clinical outcomes are better.

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  6. Thanks for share this interesting article