
Some insurers insist that patients forgo generics and buy brand-name drugs - iamjeff
https://www.nytimes.com/2017/08/06/health/prescription-drugs-brand-name-generic.html
======
cbanek
I have United Healthcare, and I have to say I've seen this happen to me as
well. I'm on a long term maintenance medication, which is delivered by patch.
I was on the generic in my previous health plan, so my new doctor prescribed
the same generic.

I used the mail order pharmacy and they told me that a 90 day supply would
cost $347. I asked why it was so much, and where my prescription benefits came
in. They said they didn't cover the generic, and I said well do you cover the
name brand one? They said they did, but they couldn't give it to me because my
doctor had ordered the generic. If I ordered the name brand, it would be $100
for a 90 day supply, which is a huge difference.

I called my doctor, and got them to change the prescription. None of the
people at United Healthcare were offering any of this information, and I
basically had to pry it out of them to figure out why they were trying to
gouge me. Also, this was their own private mail order pharmacy, so all the
money was going to them as well.

Ask a lot of questions before paying a lot of money.

~~~
pcurve
"They said they didn't cover the generic, and I said well do you cover the
name brand one? They said they did, but they couldn't give it to me because my
doctor had ordered the generic. If I ordered the name brand, it would be $100
for a 90 day supply, which is a huge difference."

3 possibilities:

1\. Your doctor wrote "dispense as written" on the script, which barred United
from substituting. This is highly unlikely because doctors only do this when
prescribing name brand.

2\. United didn't have system rules in place to flag this type of thing
because there's no financial incentive to do so for United or your employer
who is actually paying for your drug. Chances are, if generic costs $347, then
brand name costs more. When you pay $100, your employer is still paying the
remaining, which could be $250+ When you get generic, your employer pays
nothing.

3\. United didn't have system rules in place to flag this because they are
just incompetent. The fact that they don't cover generic means that your
employer is getting rebate from brand. Unless your employer is trying to save
a few bucks by intentionally screwing over their employee, United system
should've flagged this an simply auto substituted to cheaper alternative.

Either way, unless brand was materially different, United is within legal
right to auto substitute without needing a new scripts. In short, they served
you a bunch of turd sandwiches.

~~~
cbanek
I'm actually self employed, and I got this health care policy on the health
care exchanges - there's no employer in the picture, which is probably why
they're trying to shift the cost to me, as opposed to paying for the brand.

So really, without an employer, it's just because there's no financial
incentive for them to do so. Actually, it's negative incentive for them,
because they tried to get me to pay for something they wouldn't have to pay
anything for. Then for dispensing it, they charge me since they are also the
pharmacy.

~~~
drewmol
I understand if you don't want to answer this, but is there a subsity covering
part of your plan you purchased through healtcare.gov?

~~~
cbanek
No, I pay the full price myself out of pocket (and write it off on my taxes).

~~~
drewmol
Thx for the response, wondering what UHG's potential motivations may be. I
used to work in the medical billing industry, and UHG had a very poor
reputation (among major insurers) with the two healthcare management
consultants I worked closely with. (edit: UHC-->UHG)

~~~
mannykannot
The last paragraph in the article gets to the point:

“There’s only one reason why they’re requiring you to use a more expensive
product,” Mr. Frankil said. “Because somewhere down the road, somebody is
earning more money.”

The brand-name maker would like the generic market to dry up, so it may be as
simple as the brand-name maker selling its product at a reduced price on
condition that the insurer cuts off the generics. Given that some patients
demand brand-name drugs and some doctors acquiesce, this may be cheaper for
the insurer.

My doctor has a straightforward attitude - referring to patients who demand
brand-name drugs "I told them 'I take generics. My kids take generics. If you
won't take generics, find another doctor!'" (that was before the practice
described here emerged. I am sure he has something to say about it...)

~~~
saalweachter
I wonder if this is an end-run around my hands-down favorite part of the ACA,
the hard limit on the "Medical Loss Ratio" (MLR). Insurance companies must
spend at least ~80% (the number varies by plan type, but call it 80%) of
premiums on medical expenses, and if they don't, that's when you get those
refund checks in the mail. (In the 90's, you had a few insurance plans with
>90% MLRs, but by the early 2000's the average had declined to 70%, and you
had some companies selling plans to college kids with a 10% MLR.)

This is overall good, because insurance is one of the few industries that
benefits from monopoly conditions (bigger risk pools are better), so you want
a hard cap on how much money the monopolies can extract. But maybe demanding
non-generics is a way to increase "medical losses", which in turn is a way to
increase their permissible profits?

~~~
drewmol
Interesting, or a similar phenomenon to situations where in order to maximize
deductions you might want to increase charitable contributions, better to give
the money to a friend non-profit than Uncle Sam

------
AdamN
The big secret is that bio-equivalent and generic drugs sometimes aren't
effective!

[http://cmlnetwork.ca/generic-imatinib-is-it-really-the-
same/](http://cmlnetwork.ca/generic-imatinib-is-it-really-the-same/)

[http://cml-iq.com/generic-gleevec-is-the-same-the-same/](http://cml-
iq.com/generic-gleevec-is-the-same-the-same/)

Frustrating that the article doesn't point that out. These new formulas do not
need to prove they work, they just have to prove that their active ingredient
is the same after the patent expires.

~~~
stuartaxelowen
Has there been a study that established that the drugs with the same active
ingredient don't perform as well?

~~~
belorn
Regulative approval of a generic drug is given by the FDA on the therapeutic
effect of the drug, which must be within a 90% confidence interval of 80–125%
based on the original. The FDA evaluated 2,070 studies conducted between 1996
and 2007 that compared the absorption rate, and found that average difference
between generic and brand was 3.5%, comparable to the difference between two
batches of a brand-name drug.

Some comments in here talk about Active Pharmaceutical Ingredient or
excipients, but a generic isn't given approval based on their active
ingredients. This is one of the common objection given to the patent model for
drugs, in that generics still need to show that _their_ version with their
unique combination of active and excipients have the same therapeutic effect,
which normally means that they need to conduct new studies. The only way you
can "copy" a drug is if you make a identical copy in every aspect, including
the excipients, and the patent don't include enough information to do that.

~~~
kgwgk
That's not correct. To get a generic approved you don't have to show a
therapeutic effect. You only have to show bioequivalence: a similar blood
concentration time curve for the active ingredient.

~~~
belorn
[http://journals.sagepub.com/doi/10.1345/aph.1M141](http://journals.sagepub.com/doi/10.1345/aph.1M141)

If the therapeutically value of an excipient is that they change the
absorption rate of the active ingredient, then that effects the bioequivalence
of the drug. For example, comments in this thread refereed to different sized
particles in inhalers which can have a direct effect on absorption rates.

If we disregard the therapeutic effect from the rate and extent that the _"
active ingredient or active moiety in pharmaceutical equivalents or
pharmaceutical alternatives"_ reaches the site of drug action, what is left to
change the therapeutic effect?

~~~
kgwgk
The point is that you don't need to show that the therapeutic effect is the
same, you need to show that you expect the therapeutic effect to be the same.
The trials required to prove the latter are orders of magnitude simpler,
faster and less expensive.

------
PaulAJ
You guys have the most bonkers health system anyone could imagine. 1/6 of your
economy goes on "health care", but most of that doesn't actually contribute to
your health, it gets skimmed off by insurers, drug companies, individual
practitioners, hospitals and lawyers.

Sooner or later you are going to wake up and realise that a government-run
single payer scheme is the only way to go.

~~~
folli
I've yet to come across a health insurance scheme that I'd approve without any
reservation.

The British NHS that you obviously praise as the single solution is also not
without its flaws regarding quality and waiting lists. An acquainted Iranian
surgeon who works in England under the NHS remarked that he'd rather fly to
Iran in case he should ever get a surgery because the infrastructure is more
up to date and the surgeons equally well trained.

The Swiss healthcare system, which I'm more familiar with (universal
healthcare, with health insurance being compulsory, while the insurance
companies are still private), is also not devoid of flaws. The assumed
competition among the insurance companies is not working at all, resulting in
rising costs since years.

~~~
simonh
Is being devoid of flaws really the standard a system should be held to? Is
approval without reservation the only threshold for approval?

The NHS and Swiss systems aren't flawless, they have problems and mistakes get
made, but the US system is just appalling by comparison. Things that would be
considered utterly unacceptable aberrations and be immediately fixed in those
systems are routine occurrences in the US with no sign of them ever being
addressed and in fact entrenched interests actively working to ensure that
they aren't.

~~~
bluGill
All systems have flaws. You hear about flaws in the US system, but they are
not nearly as common as you think they are, at least not in my experience.

~~~
cptskippy
> at least not in my experience.

I'm glad you're here to speak for us all.

I hope you never have to deal with anyone in your family being admitted to
inpatient or residential treatment. As if severe illnesses weren't enough
stress on the family, having to immediately come up with your insurance's out
of pocket maximum deductible and then spending all of your free time on the
phone trying to find ways to keep up the coverage can just push you to the
limits.

There's nothing worse than the look on a doctor's face when he's trying to be
optimistic while telling you that your kid must be discharged because the
insurance company's doctor has deemed them better and is denying claims and
you can't afford the $2400 a day it costs to keep them there.

------
tzs
I wonder if the guy in the article has considered buying his drug without
insurance? In the case of the generic for Adderall XR it is about $70 with a
GoodRx coupon at Walgreens, which is less than the $90 copay to get the brand
drug with insurance.

Even if your insurance company lets you use generics, it is a good idea to
take a look at GoodRx, and take a look at Walmart.

I've had generics where through my insurance my out of pocket was a $20 copay,
but when I checked GoodRx there was a $12 coupon. I've had other generics,
again with a $20 copay if I got them through insurance, where they were $4 at
Walmart with no insurance or coupons.

~~~
vm
This is good advice, though the article also mentions that self-paid drugs
don't count toward deductibles. In addition to shopping around, patients
should calculate their deductibles and estimate how that might impact their
spending.

...which is a messed up, Byzantine system. I'd love a single payer system just
to crush this inefficiency out of the system and make patient's lives easier.
I would have thought healthcare is all about saving lives but in the U.S. it
seems like a dirty busy.

~~~
tomohawk
Let's see. Under single payer system, it's illegal to purchase medicine or
health care. Only the government can do it. The government does not get sick,
and so is primarily focused on cutting cost. Government picks generic drug
that works for most people and has no incentive to worry about the 5% - 10% of
people it doesn't work for. Oh, well.

This is pretty much what we have now, except with an oligopoly instead of a
monopoly. Not really seeing how going even more in the direction of a monopoly
helps.

When people can make choices, thats when things change. People actually get
sick, so paying for healthcare is more than just a cost, it can have a value
as well.

At least with the current oligopoly system, there is a small amount of choice,
and you can choose to purchase a drug on your own if what your insurer has on
offer does not work or is more expensive. We should be going in the opposite
direction - away from monopoly instead of towards it.

Instead of a single payer, we should have a single market.

~~~
maxsilver
> Let's see. Under single payer system, it's illegal to purchase medicine or
> health care. Only the government can do it.

No, Nearly every single payer system allows you to purchase extra health care,
over and beyond what the single payer system provides.

In Canada, as just one example, this is sometimes called "supplementary health
insurance". See [https://on.bluecross.ca/health-insurance/health-
insurance-10...](https://on.bluecross.ca/health-insurance/health-
insurance-101/compare-our-plans) for an example

> Government picks generic drug that works for most people and has no
> incentive to worry about the 5% - 10% of people it doesn't work for. Oh,
> well

Generally, this isn't true either. Government picks generic drugs, because it
frees up the most amount of money for them to treat other people with.

But if the government covers medications and there's a real medical reason to
need a name brand drug over a generic, they'll usually prescribe you the name
brand one automatically. Here's a list of that happening in the UK, for
example -
[http://www.nhs.uk/Conditions/Medicinesinfo/Pages/Brandnamesa...](http://www.nhs.uk/Conditions/Medicinesinfo/Pages/Brandnamesandgenerics.aspx)

And of course, as always, your still welcome to buy any name brand drug
yourself, if you like.

------
xenadu02
I've been hit by this too. The scam is really simple:

Take the example in the article: Shire normally sells Adderall for $200. They
offer to sell it to UHC for $50. The generic costs UHC $60. UHC takes the
generic off the formulary and will only pay for Shire.

For the end user the out-of-pocket cost goes from $10-20 to $50 because brand
medications are in the "Premium" category.

By saving $10 UHC sticks you with a $40 higher bill - literally 4x what they
are saving.

Targeting this specific behavior is trivially easy: change the law to require
insurers to cover generic or brand for any RX at the patient's choice.

~~~
phkahler
Better yet, from the article:

Then, a few years ago, Shire tried a new tactic: giving ever-larger discounts
to pharmacy benefit managers and insurers for preferential treatment over the
generics. That did not mean lowering the list price of the drug, but rather
negotiating rebates that were paid not to the patients but to insurers and
middlemen such as CVS Caremark.

Just prosecute them for anti-competitive practice or even collusion. What they
are doing is probably already illegal.

------
oldandtired
Interesting read of comments.

A head of R&D at Advertising Agency decided that he couldn't take any more of
the lying and corruption that occurred in the advertising industry. so he went
to work in R&D in the Medical Technology Industries Arena.

Six months later he was back as head of R&D at the advertising agency. When
asked why he had come back since advertising was so corrupt, he told them that
the advertising industry were little children compared to the standard corrupt
practises occurring in every area in the medical arena.

He had delight in telling me the reaction of the advertising agency staff at
his return.

------
hkmurakami
I skimmed the article, and there is another force at play that benefits
insurance companies.

Insurance companies have a federally mandated percentage of revenue that they
must use towards the reimbursement of their policy holders' medical costs. In
the past, this ratio was too low and they're been slapped with stricter
conditions. But Health Insurance is an industry where you can basically pass
on your costs to your policy holders with near impunity (the current
"healthcare debate" rarely discusses cost control in depth, and instead spends
time on the correct level of cost sharing). And if your overall costs grow,
then you can raise your overall revenue. And when your overall revenues grow,
you have more money to pay your executives.

Consumers lose, everyone else in the healthcare value chain wins.

------
zamalek
My sister had an acne breakout in her teen years and went on a brand-name
hormone suppliment - it worked wonders. She went on the generic and only had
problems - so far as I understand the situation the delivery mechanism is
different across brands; though it's _very_ rarely a problem for most people.
As always, it's your health at stake - if you feel as though something is not
working for you then switch.

~~~
btian
Generics mean the active ingredients are the same. Your sister's condition
probably reacted to some inactive ingredients.

Generic may work better just as brand name may work better in that case.

------
random3
Perhaps it's the same as with medical services?

Note that providers won't typically tell you the cost of a procedure unless
you give them your insurance.

Don't insurers have negotiated (lower) rates with providers? Also there's
typically a relatively large deductible.

I'm guessing that between the negotiated price and the deductible and the non-
sense of the insurer choosing something against common sense there's actually
money to be made off the patient.

So if you're charged $1000 for an MRI and have to co-pay 200 and the
negotiated cost is $200 you actually end up paying 100% of the actual cost.
You can redo the math with whatever number, but the point is the percentage
you think you're insured for is not real.

If insurer asks you to buy a 10x more expensive drug while they have a much
smaller negotiated price, they may end up paying less or actually making
money.

~~~
phkahler
My argument for years now has been that "providers" should be required to
charge the same price for every patient. In other words, insurance companies
should not be able to negotiate prices with them. The idea that an insured
person (and his insurance company) is charged less for a procedure than an
uninsured person... well that's just wrong.

As usual I like to clarify - providers should be free to set their price for a
service/product, but they must charge everyone the same for it. Different
providers would be free to charge different prices of course.

------
maxehmookau
American healthcare is weird.

I pay £9.50 for all of my meds. The NHS decides which is the cheapest version
of the drug I need. And that's what I get.

It costs £9.50 regardless of the quantity, brand or anything else.

~~~
TazeTSchnitzel
Here in Scotland, I pay nothing to get any prescription dispensed; Wales and
Northern Ireland also lack prescription charges. Wales's abolition of charges
actually saved money (because they could get rid of the means-testing
infrastructure).

~~~
maxehmookau
Yeah, I lived in Wales for a little while. That was a nice treat.

------
brooklyntribe
The mile high view of USA health care is if we can "eliminate" the poor, the
old, the sick, in the long run, it will make our economy stronger. It seems to
be doing it's thing.

The life expectancy is coming down for the first time in decades and the stock
market is at a record high. It's a "social darwinism" thing. We're a living
lab to test the theory out.

That's the mile high view. I'm not sure what the long term consequences are.

> US life expectancy drops for first time in 22 years

[http://www.cnn.com/2016/12/08/health/us-life-expectancy-
down...](http://www.cnn.com/2016/12/08/health/us-life-expectancy-
down/index.html)

~~~
Asooka
And then you all die from an infected telephone booth because all the phone
sanitizers have died out.

Joke aside, you still need people in what are now shitty low-paying jobs for a
functioning society. So if you're not going to pay the janitor enough for a
middle-class life, either make a robot to do his job, or die of dysentery. Do
you think USA will be able to make enough robots fast enough to realise that?
And will USA society be able to tolerate everyone being upper-middle-class?

------
Sindrome
My first software job out of college was working for a healthcare company. I
worked in the Drug Comparison team (which consisted of 3 people) finding
people ways to save on prescriptions by beating the system using software!
Yay, helping the world and stuff.

Actually, we ended up selling out and building systems that benefited
healthcare provider's formulary plans. For example, not recommending generics,
which was most of what we got paid 500k+ per contract to do.

We did do some amazing work on Medicare Part D stuff, tho. We saved some
elderly people tons of money by algorithmically reccomending them the right
drugs at cheaper cost.

------
0x10101
Some of this insanity is covered nicely in the econlog podcast[1] on the book
Drug Wars[2]. The NY Times always wants to throw all of the blame at insurers,
but they are trying to save money. The generic system is a Kafakaesque set of
regulations and processes.

[1]
[http://www.econtalk.org/archives/2017/06/robin_feldman_o.htm...](http://www.econtalk.org/archives/2017/06/robin_feldman_o.html)

[2] [https://www.amazon.com/Drug-Wars-Pharma-Raises-Generics-
eboo...](https://www.amazon.com/Drug-Wars-Pharma-Raises-Generics-
ebook/dp/B071RP95DN/)

------
broknbottle
I wouldn't be surprised if this was due to issues with some generics not being
the equivalent. Concerta is a weird drug with the one generic actually being
rebranded brand name. The other generics are not considered equivalent by the
FDA but the last time I checked some pharmacy such as Walgreens carry the non
equivalents. Apparently they are tied up in a court case.

[https://www.fda.gov/Drugs/DrugSafety/ucm422568.htm](https://www.fda.gov/Drugs/DrugSafety/ucm422568.htm)

------
alexc05
So I work in advertising _specifically_ focused on pharmaceutical brands. One
of my client drugs has a problem where Pharmacists are dispensing as generic
where their drug has a different Mechanism of Action and is only prescribed
after the generic fails. Pharmacists can actually be incentivized in some
cases to give the generic when the brand-name is written. Apparently they
don't even have to tell you that they're switching it.

We have multiple clients who are undertaking 'dispense as written' campaigns
with healthcare professionals to offset that.

I'm certainly not saying that it is ALWAYS the case that a drug which vs.
generic is the best choice. Sometimes they are literally the exact same
molecule.

Sometimes though, you're not getting the same level of care. Sometimes not
even the same mechanism of action.

I imagine an insurance company's position on that might be the offsetting of
liability. If a pharmacist dispenses a generic when the brand-name is
different and the treatment fails the insurance company bears the cost of that
in the form of extended care. (and possibly other things)

~~~
nsnick
If it has a different mechanism of action it is a different drug. It sounds
like your campaign is just more marketing by the pharmaceutical industry which
is illegal in most countries.

~~~
alexc05
That's right. It is actually pretty shocking (to me personally) that there are
Pharmacists in the USA who are able to legally give DRUG-B when the
prescription written is DRUG-A _and_ they are different molecules, different
MOA _and_ they Pharmacists are incentivized to do that.

It is a different molecule. It has a different Mechanism of Action and the
pharmacists STILL legally deliver a biosimilar version of a different drug and
not only is it legal, they are rewarded for it.

I'm a programmer and in the strategy meeting where I first learned that I
asked about three times if that was true. I was stunned and mildly infuriated
- but all the other people in the room were just sort of tight-lip wide eyed
nodding at me. "yes that is actually what happens"

It's part of the reason why we're focusing on DAW campaigns for so many brands
right now. Pharmacies are a "wild west"

Now this is a difference between "Generic" and "Biosimilar" \- which I may
have used an inaccurate term in my previous post.

> Unlike generic medicines in which the active ingredients are identical to
> the reference small–molecule drug, biosimilars will not be identical to the
> reference biologics. ... A generic drug, by legal definition, is an exact
> copy of its reference medicine and must have the same chemical structure.

Generics must be the exact same molecule.

I definitely know we have numerous _common_ cases of our client's drug being
written as BRANDED-DRUG-A and the generic version of BRANDED-DRUG-B is given.
Our client owns both A & B.

It's shocking. In the USA it is somehow legal.

------
Spooky23
I monitor my blood pressure pretty closely, and noticed when my blood pressure
medication changed between generic manufacturers, one particular manufacturer
was less effective, and my pressure went up 10-15%.

------
SeanDav
I just don't understand medical care in the USA. Medical treatment seems
enormously expensive, if you are not insured and you get ill, you die and yet
getting insurance seems to be resisted (Obama-care).

Would someone be able to explain (or point to an existing layman's
explanation) how medical care works in the USA, the issues with insurance and
strengths and weaknesses.

~~~
feedbeef
The US healthcare system is deeply burdened with the flow of money between all
parties involved in it. Money is integral to the system like the blood in our
veins. Without blood pumping (money flowing), the system as it exists today
dies.

How Americans obtain health insurance is largely dependent on their
age/occupation (retired, coverage thru employer, etc) and income/assets. There
is strong incentive to be insured to avoid a yearly tax penalty. People with
low income qualify for partial or full subsidy of their insurance cost,
largely footed by more fortunate tax- and insurance-paying Americans. But
unless they are poor, they are still expected to pay for services rendered out
of their deductible, a fixed ceiling in USD that they agreed upon with their
insurer (a higher deductible tends to lower insurance cost). Having insurance
also significantly reduces the "retail" cost of services and medicine (an
uninsured billionaire may happily pay $250,000 cash for an ER visit, while an
insured student may struggle to pay their $2,500 deductible for the same
thing). One upside to Obamacare is that it has taken a lot of stress away from
people, as they historically could have become destitute from massive
healthcare bills that overran obscenely high deductibles (now capped under
Obamacare). Pre-Obamacare, insurers had a deductible of their own sort, one
which allowed them to deem an overrun so high, or a health condition so dire,
that they could cut a person off (sort of like a bandwidth cap, but for human
life, a lifewidth cap if you will). One (primarily financial) downside to
Obamacare is that insurance costs have increased to pay into the subsidy and
sky-high bill bucket (and the leftovers into for-profit insurance companies'
pockets). So Obamacare, i.e. American healthcare today, is largely an effort
to not only insure every American, but also protect them from financial ruin
in a health crisis. And to accomplish that, the money must be flowing.

We certainly have a lot of amazing selfless people doing their best to heal
the sick, but as the players in this article, people like Shkreli, and some of
our congress members make so clear, follow the money trail to its darkest
depths and you will find the true face of American healthcare. It's being
stymied at every turn and will continue to be until it's either rescued by
reform or decimated by profiteers.

This barely touches on your questions and leaves out some critical details but
I hope it's of some use.

~~~
SeanDav
Thanks for this insight. It certainly does not paint a pretty picture.

------
mirimir
It's just that drug makers cut deals with insurance companies. Drop competing
generics from your formulary, and we'll give you a good price for our brands.
Or maybe on a basket of products. So you get more money, both by paying less
for the drugs, and by charging patients more.

------
mnm1
Yet another problem that can be solved by a single payer system that can
negotiate reasonable prices and doesn't need to profit off its members
suffering and death. Get rid of the insurance companies and you get rid of
this problem and a whole lot more.

~~~
briandear
Such a simplistic view. Cancer death rates in the UK are 255 per 100,000; in
the U.S. they are about 163 per 100,000.

It’s not so black and white that “single payer is better.”

Health care is always going by to be a scarce resource and it follows the laws
of economics just like anything else. It isn’t immune to reality just because
it’s important.

~~~
phaemon
_> Cancer death rates in the UK are 255 per 100,000_

No they're not. Cancer mortality rates (per 100,000) are:

UK: 109.97, USA: 105.78, Spain: 98.06, Australia: 96.36

 _> It’s not so black and white that “single payer is better.”_

In the vast majority of measures, it clearly is.

( Stats from: [http://www.cancerresearchuk.org/health-
professional/cancer-s...](http://www.cancerresearchuk.org/health-
professional/cancer-statistics/worldwide-cancer/mortality#heading-Zero) )

------
abtinf
This is a straightforward consequence of Obamacare that was predicted before
the law even passed. The imposition of onerous cost ratio requirements means a
company can make more money only by raising costs, not eliminating them.

~~~
epmaybe
I think Obama himself recognized that the Pharma lobby is one of the hardest
to beat, and decided to try and sidestep them in trying to improve access to
healthcare. Clinton tried and failed due to the Pharma lobby, Bush passed
Medicare Part D but wasn't able to give CMS price negotiation power. It's
really quite unfortunate for healthcare consumers.

------
ykler
This article left me confused about why this practice exists. It seems like it
could only be because the insurance companies are getting some kind of
kickback (maybe in the form of lower prices on drugs) in exchange for having
these anti-generic rules, but I would think that would be illegal. Can someone
who understands explain more clearly the situation?

~~~
VLM
The article is for lower upper class / upper middle class readers where
obviously what the dr writes is what is done aside from questions about "why
is money being wasted?". The actual strategy is for making money at the cost
of poorer people.

Lets say the name brand is $75, generic is $50. If a poor person gets the
generic the insurance company is out $50, well, depending on deductible, etc.
If the bureaucracy can be mysteriously blamed for not allowing the generic, at
least some percentage of the poor people cannot afford the medication at $75
therefore the insurance company is NOT out $50.

Its merely price based rationing. If you increase the cost of health care,
some fraction of the population will be frozen out of the market, just like
real estate or car prices or tuition. One of many failures of our current
economic system is maximal profit does not coincide with maximal participation
rate, some percentage will be frozen out for financial reasons, ranging from
not too many like health care, up to most of the population WRT real estate in
bubble areas. Eventually once a large enough percentage of the population is
alienated and disenfranchised from the system, there will be enough support to
burn it all down, until then its the existing slow boil.

~~~
ykler
Your argument doesn't make any sense. If the insurance company is paying for
the drug then they would rather pay $50 than $75 for it. If the person has a
deductible, it is conceivable that they would forgo treatment if the price is
$75 but not if it is $50 because they didn't think they would use up their
deductible, but then they ended up using it up anyway. The insurance company
would then save money. But this doesn't seem like it would happen often enough
to make this a good bet for the insurance company.

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mason55
Same thing for me. When I get refills I see whichever psych happens to be free
that day and they always comment on how weird it is that my insurance requires
the brand name. I always tell them that I assume the insurance company has cut
a deal with Shire and it appears I was right.

But my copay for the name brand is only $20 so it never occurred to me to
complain.

------
kindawinda
The insurers often have PBM contracts that incentivize them in filling
specific drugs. This is the most likely reason
[https://en.wikipedia.org/wiki/Pharmacy_benefit_management](https://en.wikipedia.org/wiki/Pharmacy_benefit_management)

~~~
alkonaut
Aren't pharmacies allowed to suggest generic replacement to the drug on the
recipe (unless the prescribing doctor explicitly stated to not allow it?)

Do doctors prescribe the specific brand drug and prevent changing it to
generics, because the insurer tells them to? That sounds like a solvable
problem: doctors that prevent swapping for generics must have valid medical
reasons, not only economical reasons. Makes sense?

------
colordrops
I have to take levothyroxine and my endocrinologist insists that I take a
particular name brand. The amounts are in micrograms and the dosage varies
across brands, and since various pharmacies use different generics, the only
way to get consistency is through sticking with a particular brand.

------
Shivetya
I am sure others have had the issue where you shop around for free versions of
prescriptions only to have the insurer tell you to sign up for 90 day supply
with a cost. They seem rather insistent on it but there have been no
repercussions for my ignoring them

------
egeozcan
I'm relatively new in Germany. As far as I can remember, the doctors always
prescribe the generic drug, but I can't verify because I never keep the
prescriptions. Can someone confirm?

~~~
thesimon
Does not really matter a lot what the doctor exactly writes on your
prescription, because "aut idem" will not be ticked on the prescription in
most cases.

The pharmacy then does most of the work and checks with your insurance which
drug manufacturer has a contract with the insurer and hands you the cheapest
one. This usually is a generic and you would get that even if the doctor wrote
the brand-name one on your prescription.

The doctor can decide to tick "aut idem" and you would get exactly the
medication by that exact manufacturer prescribed, but you might have to pay
extra at the pharmacy for this so this is really uncommon.

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denisehilton
What's the guarantee that branded drugs won't have any side-effects. There's
none. and they're pretty expensive too.

------
agumonkey
People will anyway.

You only needs the slightest derivation from one's habit and it's over.

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crb002
Adderall XR and Metformin actually are better than the generic.

~~~
LammyL
Metformin is the generic. Glucophage is its equivalent brand.

~~~
dp-tyvek
OT, but how did the brand name Glucophage get approved? I don't see how
calling a drug "glucose eater" is anything but misleading.

~~~
jameskraus
In general, stimulants were once more popular as apatite curbing agents. When
the drug was developed, they probably thought people would use it to lose
weight, so 'glucose eater' has the same general effect they were going for:
weight loss.

------
throwawaymanbot
Even having health insurance is not enough to afford healthcare in America
these days. The fragmentation of American Healthcare in to this S##tshow, whos
only function is to gouge the consumer, is proof that the US needs single
payer, like the rest of the world.

