Is This a Pharmaceutical Shell Game? Where Did the Money Go?

ok, i have been in the pharmaceutical business for 19 years (just retired)--let me try to explain. The pharma companies offer co-pay cards or mail in rebates to get you to use the name brand drug instead of a generic or just to reduce the amount that you have to pay at the pharmacy. There are lots of people with high co pays that just walk away without getting their prescription filled and the patient is not getting the benefit of the prescription that the doctor ordered. No sale at all. If the pharma company subsidizes your RX with a $20 co pay card and your co-pay on brand drugs is $30, then you pay $10 at the pharmacy to get the branded drug. That $10 may be cheaper than what you would pay for the generic. The pharma company collects a contracted amount from your insurance company or your pharmacy benefits manager (PBM) on the drug that has been filled. That is much better than no sale at all and the patient gets the medication they need. The patient is happy. The PBM's complain because they could have paid out less on the generic. If you go online and search under your branded drug name, there are often coupons or copay cards that you can print out and take to your pharmacy. Some are good one time and others are good on an ongoing basis. Generic or Brand??? does it make a difference?? Sometimes it does, and sometimes it doesn't -- it depends on the classification of the drug, the drug and the patient! PHARMA guidelines prohibit paying a prescriber a kick-back or a rebate based on the amount of pharmaceutical drugs that they write. Doctors do not "earn" trips for the number of prescriptions they write. Pharma companies have not even been allowed to give out pens or notepads for more than 3 years. Ok, why wouldn't you want the generic? Is there a difference in the number of times you have to take it a day? Is the course of medication the same or longer? Are there less side effects with brand name drug? Ask your doctor why he or she recommends the brand drug? There may be a significant reason or he/she may be willing to write the generic for you.

You should ask your doctor if he's getting kick-backs from the big pharma company. That's my first thought.

The pharmaceutical company is trying to get you to use an expensive drug that works wonderfully in the hope that you'll keep using it. There are Rx plans that will cover it - and they negotiatie a discount with the manufacturer to pay only $200 for it (numbers are illustrative only).

They give you the rebate which usually would cover the plan copay ($50 -$75 for new high cost drugs is pretty common these days). But since your plan won't cover it at all the people who work in the pharmacy assumed the rebate card wouldn't cover it. Once they made a few calls they discovered it would. Or - sometimes the Rx plan requires pre-authorization for drugs like this - it's not that they won't cover it outright - it's that the doctor has to call the Rx plan and explain why other, less costly drugs won't work. If they can do that to the insurance company's satisfaction the drug will be approved.

Finally - no the doctor doesn't get kickbacks, per se, but they can earn trips to medical conventions and even new medical equipment if they write more than a certain number of prescriptions.

Oh god, how to explain this. I don't think I can. There are so many numbers flying around out there who knows what cost what.

An example is my Adderall. 280 a month where the generic is 110. The copay for brand is 50 and generic is 10. So my insurance made a deal with the makers of Adderall to sell it to them cheaper which they agreed to because the generic is out so they will only cover the brand name and collect a 50 dollar copay instead of the 10 even though it cost them the same as the generic after the deal.

Clear as mud!?

Oh, no your doctor isn't getting kick backs. They have those deals so you start using the brand name and they can use that to pressure your insurance to cover it. Then they can sell it at full price.

i believe the pharma companies are required to offer programs for people that don;t have insurance coverage for the medication, that is how it is done. My husband has a card for one of his meds because the co-pay is really high. The card covers $25 of the med, cutting the medication cost almost in half for a month's supply. I think I read somewhere about this.

I always look at the paper that comes with scripts from cvs when i leave... my med from the dermatologists cost $840 a month my co-pay $10, birth control $30 copay $10... i am amazed at how much drugs cost, and then again i am more amazed my insurance company hasnt said our family plan should go up due to my dermatology meds and labs at the moment... that is my rant, doesnt answer your question... but i am amazed!