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NO. NOPE. MAYBE NEVER. GO AWAY!
“
Cleopatra
by Mary Barry, MD
, the Queen of De Nile,” was something we chanted on the playground at Christ the King, for reasons lost in the mist of time.
I thought about her again when reading the myriad reasons that pharmacy benefit managers, or PBMs( I liked other translations of these initials, none of them polite –“ Puky” for instance). I would think, what kind of person does this job without becoming paranoid? They are constantly subjected to complaint.
The Cover My Meds website notes that medical practices“ complete an average of 43 prior authorizations per physician each week.” Not per practice – per doc! Filling these out is a major, ongoing headache for primary care doctors especially. Each insurance has different“ nogo” lists; each patient has different allergies, intolerances and financial capabilities; each medical assistant long ago lost patience with the automated phone trees beloved of large corporations. Each PCP, holding tight to professionalism and our care for our beloved patients, grinds his or her teeth to shreds, but we make the calls necessary to ensure that we tried everything to get our patient the medicine that works best and is best tolerated.
And of course, we fill out the forms.
The first hurdle is making the patient try all the required generic equivalents: this puts the extra cost and the extra effort squarely on the patients’ shoulders. I would tell the patient,“ You have to pay the generic copay for all the similar meds your insurance company thinks would save them money, until we have gone through the list, for you to get this brand name medicine approved and covered.” Their jaws would drop.
“ You mean if I have to take six different ones it could cost me at least $ 60 when we already know the med we want?!”
“ Yes, because their money matters more to them than your money.”
I used to run into the ace inhibitor / angiotensin receptor blocker( ARB) stop sign all the time. If you have had angioedema to an ace inhibitor, it is unwise – I would say idiotic and potentially lethal – to try an ARB, although the PBM people cited studies that say it can be done safely“ in a monitored situation with emergency treatment available.” They wanted the patient to try the med anyway.
Imagine the conversation:
Me:“ Well the drug company wants you to try Losartan – which is potentially cross-allergic – even though you had to go to the ER for the lisinopril.”
Patient:“ Are you kidding me?!”
Me:“ No. Not only that, but to take the first dose safely, you need to be in the ER or the allergist’ s office with an IV running, and with epinephrine, oxygen, cardiac monitoring and CPR available.”
Patient:“ Are they nuts?!”
Me:“ No. They are blindly following their decision tree. They want you to prove that you will not swell up, itch, have hives and then have your airway close up, so that they can save money on the meds they get at better rates from the manufacturers.”
Patient:“ They’ re nuts.”
Me:“ Seems to me the expense of an ER visit, specialty care, possible admission, risking death and or lack of oxygen to the brain – and the lawsuits that follow – all these would cost vast amounts
36 LOUISVILLE MEDICINE OPINION