Little Known Insurance Tid-bits

Right now I am going to share with you some things that I learned while working in the pharmacy to help you better understand how the insurance companies work.  Because of this understanding I have been able to get my insurance company to pay for things they normally wouldn’t have.

BRAND VS. GENERIC

First off I am going to explain brand named drugs versus generic.  We know those people, as you might be one of them, that say brand and generics do not work the same.  Then you have those people that say that they are all the same quit your whining. Well you are both right.  How?

The drug companies apply for a patent for a specific drug and they start their research and clinical trials. This process takes years and years to complete. The FDA then approves said drug so it can be dispensed to the public. This drug is called your BRAND named drug. Once the patent expires any other drug company can buy the recipe for this drug and dispense it as a GENERIC. Because the drug companies don’t have to pay for all the years of research, salaries, clinical trials, and equipment they can charge a lower rate for the drug and still turn a profit.

Now there are two components that go into a drug, active ingredients and inactive ingredients. The active ingredients make the drug do the specific job it’s assigned to do and the inactive support the active ingredients.  The inactive ingredients in a GENERIC do not have to match the inactive ingredients in a BRAND to do the job. This is why some generics work and some don’t. 

Here’s the breakdown…

Drug: BRAND           
Active Ingredients: A, B, C, D   Inactive Ingredients E, F, G, H

Drug: GENERIC A   
Active Ingredients: A, B, C, D    Inactive Ingredients E, F, G, H

Drug: GENERIC B    
Active Ingredients: A, B, C, D    Inactive Ingredients I, J, K, L   

When a GENERIC works just like the BRAND you are receiving GENERIC A. The pharmacy lingo is that the drug is biochemically identical.  When a drug doesn’t work the same you are receiving GENERIC B. 

I do know from working at CVS that it is their policy to not replace a BRAND drug with a GENERIC unless it is a biochemical match.  I don’t know about any other pharmacies.

A DIRTY LITTLE SECRET

Aside from the reasoning above that I gave for brand name drugs to be so expensive I have something else to throw in the mix.  Of course the insurance companies encourage you to go the generic route because it will be at a lower cost to them.  If your doctor writes the prescription for a brand name drug then you have the choice of getting the brand or generic. However if the doctor writes the prescription for the generic then you must get the generic. The insurance company and the pharmacy are not being difficult, it’s the law.

Now let’s look at your insurance co-pays.

generic $10.00

common (or formulatory) brand name $25.00

uncommon brand name $50.00.

Here’s the scenario, you bring a prescription to the pharmacy that is written for a brand name drug. The pharmacy has to tell the insurance company one of three things and this helps determine the out of pocket cost to you. 1.) you want the generic drug 2.)  the doctor is requesting brand name 3.) the patient is requesting brand name. All of these are specified on the prescriptions.

You choose to get the generic and you pay $10.00

The doctor says you need to only get the brand name $25.00

You insist on getting the brand name even though your doctor didn’t specify $65.00

$65.00! Where did that come from?!?! That would be your brand name co-pay of $25.00 plus the difference between the brand name co-pay and the generic co-pay which is $40.00. So $25.00 + $40.00 = $65.00. Now again if there is no biochemically matched generic you will be given the brand and only pay the $25.00 regardless of what the doctor writes.

STEP THERAPY

Another obstacle is what is called step therapy.  This is a big reason insurance companies deny payment and you have to fight with them.  If you only take one thing from this post take and remember these two words PRIOR AUTHORIZATION. Insurance companies want you to start out with the least expensive and least potent drug obviously. To give you an example please see below.

Drug A            least potent and least expensive

Drug B

Drug C

Drug D

Drug E             most potent and most expensive

You have been going to your doctor and he gives you Drug A to try.  He gives you a sample from his closet. A few months go by and Drug A is not working so the doctor looks at his supply and gives you Drug B. A few more months go by and Drug B is not working so the doctor writes a prescription for Drug C. You go to the pharmacy and the insurance company denies the claim and refuses to pay for the medication.  Why?  Because the insurance company does not know that you received samples of Drug A and Drug B, they just assume you are jumping right into Drug C.  They want you to try Drug A and Drug B first understandably. The first thing you should ask is if the insurance will cover the drug with a PRIOR AUTHORIZATION. Most cases they will. You or the pharmacy will call the doctor and notify them. The doctor will then tell the insurance company that you have indeed tried other therapies then BAM! It’s covered!  The insurance company just has to update your profile in the computer so when your pharmacy re-bills the drug it’s covered. I hope that this post has made you more aware of how things work because of course you are always your biggest advocate.

Posted by Unknown

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