Something smells foul in this situation. Why does a prescription drug plan prefer a brand name drug (Nucynta) that costs over four times as much as a generic (oxycodone with acetaminophen)? We are talking over $400 versus about $100 respectively. You can be pretty sure it’s not therapeutics!
My cancer patient was once again besieged by his insurance company. He had just been enrolled in a new Medicare Part D plan and it seemed that every facet of his medication therapy was being challenged. This is a patient whose health care team has worked diligently to not only keep him alive but provide a decent quality of life. Now his anxiety level was being ratcheted up by long letters from his new drug plan that threatened the successful management of his disease.
Of course, the first hurdle was getting new “prior authorization” for meds like the tincture of opium that he needs to reduce his number of bowel movements to less than 15 per day from the 30-something he experiences without treatment. Fortunately, we were able to anticipate this hurdle and good communication with the doctor, his community pharmacy, his specialty pharmacy, and the plan, allowed us to get the prior authorization in time for his next prescription.
The latest letter (four pages!) from his plan stated that his Rx for oxycodone with acetaminophen would only be covered one time for a 30 day supply and then he would have to switch to the formulary drug, Nucynta. The reason given is that although the oxycodone product is on formulary, “you must first try other drug(s), specifically NUCYNTA IR, as part of what we call a step therapy program.” This patient has been battling colon cancer for five years! He has been through every possible “step” to manage his pain that you can imagine! So now his health care team is again forced to spend time convincing the health plan to cover the drug that works best for this patient.
Trying to determine why this step therapy was required led me to look into the Medicare Part D money trail. Although I cannot say that this patient’s plan is involved in any of the practices that I uncovered, the fact still remains that a higher priced drug is being “pushed” on plan patients.
Some of the strategies that may lead to a decision like this have been exposed in the past. For instance, pharmaceutical manufacturers settled suits where they were shown to have given “concealed discounts” to pharmacy benefit plans in the form of interest-free loans, “data processing fees,” and “risk share” rebates tied to growth in an insurer’s outlays for the drug companies’ products. There have also been instances of “price bundling” where one or more products in the manufacturer’s catalog is steeply discounted to be put on a plan’s formulary, while other, expensive brand name drugs also get added to the formulary as part of the “bundle.”
Prescription benefit plans also have a financial interest in getting discounts from manufacturers, especially for drugs sold during the patient’s pre-donut hole spending. During this part of coverage the plan gets a direct subsidy from Medicare. This is a fixed subsidy, unaffected by any discounts that the plan may have negotiated with manufacturers. Once the patient is past the donut hole, the subsidy is based on actual drug cost. Apparently we can thank Congress for that little gift to insurers.
That is how we have the paradox of a $400 drug which may or may not benefit my patient being preferred over the low cost generic that has worked well for him over several years. I have no idea why this drug plan prefers Nucynta over generic Percocet. I am certain, however, that is more about money than therapeutics.