Stat News has an article on a DOD IG report on the White House pharmacy during the Trump Administration. Lots of things stood out to me but one that is relevant for a lot of insurance design is the brand to generic spread:
White House medical staff also regularly asked for brand name medications like Ambien and Provigil instead of the generics because “their patients prefer using the brand name drugs,” a practice that contradicted military policy. Those two drugs alone cost the government $144,520 over the period from 2017 to 2019, whereas the generics would have cost $2,064, according to the report.
72:1
WOW
That is an incredible pricing spread. It is more than I typically see but I don’t spend a lot of time thinking about pharmacy pricing (one of my co-authors spends most of her day thinking about this, so I will learn a lot from her!). This is why insurers have fairly complex and confusing formularies that strongly encourage people to use generic drugs if available with low to no co-pays or deductible exposure.
Open Thread: Jasmine Crockett Is a Force to be Reckoned With
lowtechcyclist
I don’t know if there are any instances where there’s a noticeable quality difference between the brand names and the generics, but AFAICT it’s somewhere between infrequent and rare. Anytime a doctor prescribes a drug for us using the brand name and the pharmacy asks if we’re OK with a generic (often they have the generic on hand but they’d have to order the brand name), we always say yes, and we’ve never had a problem.
The sleeping pill I occasionally take for my early a.m. insomnia is Zaleplon, which is the generic version of Sonata. Works fine. My wife takes the Wal-Mart knock-off of Prilosec, ditto.
Kristine
With some drugs (thinking tablets), there can be enough of a difference in formulation that release/absorption can differ and the patient may need to adjust dosage accordingly. That can take time and depending on the condition being treated may be something the patient doesn’t want to deal with.
I do understand that cost is a definite consideration. I take a brand name because of the above reasoning, but still may talk to my doc about making the switch.
catclub
I bet there are people who respond less well to generic drugs as a psychosomatic effect.
Brand loyalty is a thing. Just ask which mayo they prefer.
Gvg
My sister the doctor used to have to spend a significant amount of time correcting pharmacies that automatically changed her choices with generics or “just as good” eqivalants. She came to resent those insurance overrides for wasting her time. She almost always prescribed generics. But there were good reasons sometime for going brand. The coatings sometimes were very significant. They could make the release more even or better prevent stomach upsets. Also the dyes could cause allergic reactions in certain patients. The doctor knew the pharmacy or insurance didn’t. Basically if a doctor says don’t substitute, they shouldn’t. The process is very labor intensive.
AnonPhenom
Bioequivalence standards have proven sufficiently reliable.
It’s a matter of consumer perceived *value*.
(40 years a pharmacist)
Kineslaw
My niece takes an ADHD drug. One generic brand works fine for her, but there is another generic brand that sends her into a tailspin.
gvg
The white house was probably overdoing the brand name allowances. But there are real differences, and the price spread can be huge. It might not take that many to make for a large price difference.
cmorenc
The actual active drug is usually but a fraction of the actual mass of a pill or liquid solution, and what comprises this binding agent, filler, or solution agent can make a noticeable difference (at least to me) in how smoothly (or not) my body (esp GI tract) reacts to this supposedly inert portion of the drug’s packaging. I particularly notice this with various brands of ibuprofen – yes the drug itself tends to irritate some people’s GI tract, but for me, the coating and filler makes a substantial difference in whether its absorption is unremarkable vs a bit upsetting. With prescription drugs vs generics, sometimes there are similar differences in how smoothly (or not) the drug goes down, depending on the pill packaging material.
Frank Wilhoit
The New Thing seems to be generic drugs whose efficacy varies from different manufacturers. When a pharmacy switches brands from one that works to one that doesn’t, the only option is to hope you can find someone who still stocks the good ones and buy them as a self-pay.
One suspects that this is closely related to e.g. the recent discovery that lead chromate was being sold as turmeric, which is probably the tip of a very large iceberg.
Jay C
TBH, the brand/generic differences in medications can (and usually do) vary greatly depending on:
Mrs. Jay is, sadly, a chronic-pain patient (and has been for years); so we have an unfortunately long experience in dealing with the subject. We are lucky in that the generics covered by our prescription plan ARE generally effective; but there are a few meds that Just. Don’t. Work. And need the “brand” version to be effective. Fortunately for our budget, they are few and far-between….
Villago Delenda Est
Take the $142,000 odd difference directly out of Ronny Jackson’s ass.
Yarrow
Some Endocrinologists specify brand name thyroid medication (Synthroid) because it has a dependable dosage. Costs way more but they insist.
Quite a few years ago I knew someone who was taking the generic Wellbutrin. He was having some issues and his doctor said it was a known issue that the generic Wellbutrin wasn’t working as well and to try the name brand. Prohibitive price in the US so the doctor gave him he name of a Canadian mail order place and he ordered the name brand from there for not a lot more than he was paying in the US.
Drug pricing is so weird and complicated.
JoyceH
Interesting that the two drugs cited are drugs to put you to sleep and wake you up. Place sounds like a 1930s era movie set. And pretty much what I’d expect from a Trump organization.
Villago Delenda Est
Deliberately, the Sacklers wouldn’t be billionaires without it.
Ohio Mom
My neighbor who is a pharmacist at the V.A. said she never believed patients who insisted the generic or one particular brand wasn’t as effective for them until she experienced it with one of her medications.
Now almost everything I take is a generic and I’m perfectly happy with them. And I assume that is true for most patients. But if something only happens onetime in a million, someone has to be that one time.
Delk
Last week I got my final EOB for 2023. My total drug cost was $60,335.67.
Ohio Mom
Why does medicine cost so much? Lots of blame belongs to Pharmacy Benefit Managers. A primer: https://m.youtube.com/watch?v=5rw4kNHNZyk (two minute video).
Too long, didn’t watch; corruption.
Anonymous At Work
I have had some issues with PPIs for my GERD. Nothing worked as well as Nexium, but that was the first PPI I was on when my GERD was both acute and untreated/undiagnosed for 6 months. This was early aughts, so I don’t know if there were generics then. When my GERD returned, generics weren’t good at slowing it.
Leto
The WH physicians should’ve just printed their own label with “Ambien”, but filled with generic. Like any of them can read/pay attention. But it’s also another instance of just flouting the rules with no consequences.
Kelly
Any drugs I’ve taken work exactly as expected. Mrs Kelly often has the most obscure bad reactions to pharmaceuticals. We’re all built a little differently. I’m a horse she’s a unicorn.
xeny323
Is no one going to comment on the two medications mentioned? Provigil is for narcolepsy but it often used to keep awake and alert. Ambien to sleep so seems interesting that lots of people are taking those two.
Barbara
The typical issues are allergies to non-active ingredients, and subtle differences in blood concentration levels, especially for drugs like anticoagulants with a risk of bleeding. If available, it’s probably better to start with a generic rather than switch from one to the other.
When my son had a respiratory infection I had to give him albuterol sulfate, very widely available as a generic but with a brand alternative. The problem with the generic was (a) it was hard to find and (b) what I did find required me to dilute it to a weaker strength. The thought of having to do that every two hours around the clock for a three month old infant, much less instructing other members of the household in how to do it, was just just too much for me, so I asked for the brand in the specific strength level.
CaseyL
When I was taking Effexor, I noticed a big difference between the brand version and the generic version (venlafaxine). But that could easily have been a change in my biochemistry rather than the drug.
As it is, I’ve weaned myself off anti-depressants (at least for now). If I had to go back on them, I’d prefer to try Wellbutrin, see if the different treatment mechanism suits me (something something L-Dopa rather than serotonin uptake).
cain
Was I the only one who read the title and thought we were going to talk about sandwich spreads?
WaterGirl
I fear that this thread title will be catnip for the pharmaceutical blog spammers.
I am having flashbacks to the hundreds and hundreds of spam comments we got from a post that had “gamer” in the title.
karen marie
@Villago Delenda Est: I want to know who was getting that much Ambien.
Ann Marie
Right now I’m going through pharmacy hell trying to get my prescriptions transferred from one to another, all because the first pharmacy wasn’t able or willing, not sure which, to provide the generic version of my essential asthma medicine on a timely basis. I just retired and my new Part D prescription insurance charges a fortune for the brand name version. Just trying to get the first pharmacy to transfer my prescriptions is taking forever. Also, when I was working, they always gave me the brand name when my doctor actually prescribed the generic. I didn’t find that out until I was choosing my Part D plan.
Brachiator
Until a few years ago, I wasn’t taking many medications, so I assumed that a brand name mainly represented a drug company’s desire for profits and investment recovery in a particular medication. I assumed that a generic was just as good.
I have never had a problem with a generic drug, but I appreciate the issues raised by many comments here and will pay more attention in the future with new medications. Learned a lot.
I have only had one issue with ordered medication. My doctor ordered a time release version of a drug, one tablet a day. At one point, the pharmacy substituted a two a day dose. I asked and they insisted that there was no error, but could not give me a clear answer.
After repeatedly questioning them, I determined that changes in my health insurance plan meant that the insurance would no longer pay for the time release version.
ETA I still mainly buy the generic grocery item. Rarely seen a significant difference between generic and the brand name version.
Feathers
@Kineslaw: ADHD drugs are notoriously fickle. Small dosage differences can make a big difference. When people say. the drugs made them “zombies,” it was because they were on a too high dose. Too many doctors don’t realize this and don’t test higher and lower dosages until one is found that works.
Worked for a person doing healthcare cost research. Told him about having to get a new ADHD prescription every month, with doctor’s visits. That once you were a regular, it was every three months. His jaw dropped. No idea that this was a cost that lawmakers just added onto the system.
emjayay
I thought that besides maybe the President the rest of the Executive branch people would just be on whatever approved FEHB plan they chose, just like any federal employee. In all or almost all of them getting a brand name instead of generic drug would cost the employee, not the plan. I’ve been taking a thyroid supplement for decades. One doctor thought the name brand was better, claiming that the dosage would be more correct, and in that case it didn’t cost a lot but I was charged about $20 instead of nothing. I switched my primary care doctor for other reasons and went back to generic.
By the way, blood tests over the years never showed any difference.
If the government was paying for the drugs then it seems like the White House has its own little luxury concierge health care deal unlike that of the rest of federal employees?
evodevo
@karen marie: LOL two guesses…
Alice
@Yarrow: Yes, levothyroxine versions are notorious for varying in potency. For about a year, every refill I got had a different manufacturer and it would knock me sideways for a couple of weeks until my body adjusted – I’d either be bouncing off the walls or barely able to stay awake. Really frustrating.
Barbara
@Feathers: It’s not a cost just added by lawmakers to the system. It’s because many are classified as drugs of abuse, and are Schedule 2 products. One of my kids has taken different ADHD medications and she was asked repeatedly in college if she would sell them.
Barbara
@Ohio Mom: I am not going to defend PBMs but pharmaceutical pricing is first and foremost set by manufacturers, who of course are all too willing to deflect blame on to other parties. If someone offered them a deal, “we’ll outlaw PBMs if you give us Germany’s pricing,” do you really think they would take it? Umm, no, they wouldn’t.
And apart from PBMs and manufacturers there are so many levels of various types of entities that make a lot more money when drugs cost more. All willing to give you all sorts of reasons why it is right and just for them to hang on to their bit of the pie.
AnonPhenom
@WaterGirl:
Or those researching why nobody trusts anybody/anything anymore.
Anne Laurie
It sometimes works the other way around, as well… my brain seems to be incapable of adjusting to the new(ish) name-brand statins, so my pharmacy claims they have to special-order old-fashioned generic pravastatin!
StringOnAStick
Wellbutrin in the original form (now called XL for extended release) was an osmotic pill, a plastic casing with a divider in the middle and salt on one side, the drug on the other. As water flows into the salty side t to reach equilibrium with the salt level outside the pill, a uniform amount of drug is squeezed out into your system from the other side. Brilliant, really. Then I got given generic, pressed powder coated pills; definitely didn’t work nearly as well and seemed to trigger a big series of migraines. Fortunately the osmotic pill form is now generic.
Hob
Btw, in case anyone hasn’t read the linked article, or the DOD report that it was a summary of… David’s comment that “lots of things stood out” was putting it mildly. The cost issue he mentioned was the least of the fantastically corrupt/flaky/weird practices they uncovered. This pseudo-pharmacy, not staffed by pharmacists or any other licensed personnel you would expect, was handing out you-name-it like candy and barely keeping records, and it’s unclear what agency if any was actually in charge of it. I imagine the chances are slim that any of this will stick to Trump, but at the very least it’s exhibit #2,999,999 in a series of “what an effective and principled administration does not look like.”
Origuy
@Yarrow: My housemate takes name brand Synthroid because the generics simply do not work for her. She has to bring it from home when she is admitted to the hospital because the hospital pharmacy does not keep it.
There are other medications where she is allergic to the dye in some brands.
Another Scott
@Villago Delenda Est: Yeah.
VanityFair.com (from December 2019):
From the STATNews article:
Sounds like the probe was started based on complaints about Ronnie. Maybe all the bad stuff happened on his watch (but that would be hard to believe). Maybe the press will ask him about it!
Yeah, I slay me. :-/
Cheers,
Scott.