Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Wednesday, March 26, 2003
    Now I'm Really Mad

    Last week I saw a patient who had GERD (severe acid reflux and heartburn), who I'd placed on ranitidine (generic Zantac) at the maximal dose of 300 mg daily. She was doing well with it, but noted that if she missed her dose by even a few hours her symptoms would return. She was having symptoms of reflux during the daytime as well as at night.

    She showed me a letter she'd gotten from her pharmacy benefit manager, Medco Health - yes, I am going to name names here. These people make me furious. I quote here partially from the letter:

    We are offering a new digestive health management program, called Positive Approaches, at the request of your plan sponsor (that would be her insurance company: Merck Medco contracts with several insurance providers to provide pharmaceutical benefits).

    As part of this program, your medications may be reviewed with your doctor or other healthcare professional to determine the most suitable and cost-effective treatment for your condition.

    Then followed a list of two generic medications: ranitidine and cimetidine, as well as Pepcid (famotidine). These are the three "H2 blockers," the original anti-ulcer drugs. Now that more advanced drugs, the "PPI's" (proton pump inhibitors) are available, the costs of H2 blockers have dropped significantly... especially cimetidine and ranitidine. They continue to be excellent methods of treatment for GERD, and very inexpensive.

    The point of the letter was to tell the patient that, without getting special authorization, the patient could not continue on the maximal dose of the H2 blockers (in my patient's case, 300 mg) but would have to cut back to the mid-strength dose (150 mg). This for a generic medication. PPI drugs are limited in many cases, and rightly so, as many patients don't need them but will do fine with the less expensive H2 blockers - but I have never seen an insurance company quibble about H2 blocker dosing. (The patient said of the letter, "They sent it the minute I filled my prescription... I got it later that week.")

    I called up Medco to make my case for continuing to maintain the patient on 300 mg. During my conversation with the pharmacist, I told them how ridiculous I thought this was and that I had never seen such a request before. "Is it really worth it to do this?" I asked. "How much money can they possibly be saving?"

    The pharmacist stated that he didn't know, but that the company must be saving a significant amount of money or they wouldn't have begun this protocol.

    Later that day, to satisfy my curiosity, I called the pharmacy downstairs from me and asked for a price quote on a month's supply of ranitidine, both for 150 mg and for 300 mg.

    Thirty 150 mg tablets cost $13.
    Thirty 300 mg tablets cost $15.

    Let's do the math here, folks. That's two dollars a month.

    Granted, if someone only needed 150 mg daily, they could get that dose by buying 300 mg tablets and cutting them in half for a total cost of $7.50 - but to put it in perspective, a month's supply of the PPI drug Protonix costs $130 for thirty 40-mg tablets.

    I don't see the benefits of fighting over seven dollars a month when the company could be saving $115. Do you?



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