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It’s standard advice for consumers: If you are prescribed a medicine, always ask if there is a cheaper generic.
Nathan Taylor, a 3-D animator who lives outside Houston, has tried to do that with all his medications. But when he fills his monthly prescription for Adderall XR to treat his attention-deficit disorder, his insurance company refuses to cover the generic. Instead, he must make a co-payment of $90 a month for the brand-name version. By comparison, he pays $10 or less each month for the five generic medications he also takes.
“It just befuddles me that they would do that,” said Mr. Taylor, 41. A spokesman for his insurer, Humana, did not respond to multiple emails and phone calls requesting comment. With each visit to the pharmacy, Mr. Taylor enters the upside-down world of prescription drugs, where conventional wisdom about how to lower drug costs is often wrong.
Out of public view, corporations are cutting deals that give consumers little choice but to buy brand-name drugs — and sometimes pay more at the pharmacy counter than they would for generics.
The practice is not easy to track, and has been going on sporadically for years. But several clues suggest it is becoming more common.
Tyrone’s comment: The next time you run a claims analysis (re-pricing) here is what I want you to do before deciding which PBM to go with – assuming cost and transparency are important factors in your selection process. Take a look at the contract and based upon the language in said contract ask yourself which vendors’ numbers are most likely to hold up? I don’t care what your title is Benefits Director, Corporate Attorney or CFO if you’re not an expert in the PBM space, far beyond our functional role, find someone else to interpret the information. Finally, be wary of anyone who claims to have it all figured out. This [pharmacy and pharmacy benefits] has been my obsession now for 15 years and still rarely a day goes by when I don’t learn something new.
In recent months, some insurers and benefit managers have insisted that patients forgo generics and buy brand-name drugs such as the cholesterol treatment Zetia, the stroke-prevention drug Aggrenox and the pain-relieving gel Voltaren, along with about a dozen others, according to memos and prescription drug claims that pharmacies shared with ProPublica and The New York Times.
Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif., said he began noticing “very odd things” going on with Adderall XR and other attention-deficit drugs about two years ago. He began receiving faxes from pharmacies telling him that he had to specify that patients required brand-name versions of the drugs.
He had been practicing for 40 years, but until then had never had a pharmacy tell him that he had to prescribe a brand-name drug instead of a generic.
This article was written through collaboration between The New York Times and ProPublica, the independent, nonprofit investigative journalism organization.
