The merger of Express Scripts and Medco gives us even fewer choices for mail-order pharmacy options where patients can receive 90 days of their prescriptions at a time. Receiving 90 days at a time has been great for my patients in many ways, but there are some instances where it doesn’t work. For those times, you will need to find a local pharmacy to help you out. Here are the 10 issues my patients and I run in to where mail-order pharmacies aren’t so good.
1. You need something and you need it now: Antibiotics for a sinus infection, cream for a rash, treatment of a urinary tract infection, and the list goes on. You will need this the same day and your mail-in won’t help you there.
2. Fluctuating doses: I have many patients on high blood pressure medications, for example, where we are changing the dose around. Weight loss and exercise among other things can lower your blood pressure, and we may be able to lower the dose of your med. If we’ve been tinkering with your dose, a 30-day prescription may serve you better than filling a 90-day prescription only to toss it in the trash.
3. We aren’t sure it’s going to work for you: Migraine medications, allergy medications and heartburn medications that we start on you may not work. If they don’t work (bummer) you will be tossing those pills in the trash. Thirty days for a new medication you are trying out makes more sense.
4. It’s new and you may experience side effects with it: I have started patients on antidepressants, urge incontinence meds, blood pressure meds, only to have them tell me the dry mouth/dizziness/fatigue is intolerable. Then you are stuck tossing out 90 days of pills.
5. Start low, go high: Again, for antidepressants, pain medications, and meds for neuropathy, among others, I like to start a low dose for 2 – 3 weeks then increase it. This way you may tolerate the medication better and we can see how high we need to go for effect. Three-month supplies don’t work well for this.
6. You need it short term: If you only need 14 pills of zolpidem before you leave on your trip, a local retail pharmacy will suit you better.
7. Human contact: If you want to talk to your pharmacist about drug interactions or side effects, your local pharmacy fills that need best.
8. Human voice: If there is a problem (you get the wrong size needles for your insulin, for example) or if you have a customer service issue, I have heard from patients it is very difficult to get a voice on the phone to help you out. In fact I’ve heard it can be a nightmare with the mail-in pharmacies.
9. Slower to get generics: Mail-order pharmacies are slower to get generics and dispense 10 – 13% less generic medications than retail pharmacies.
10. You don’t have the 10 – 14 days to wait.
What did I miss?
This past year and a half has brought us generic versions of some blockbuster drugs. What this meant was the expensive brand name drug isn’t your only option. While most of the time, when your medication becomes generic you will save money, strangely it may also hurt you. If you are on a brand name medication that now has a generic option in the same class of drugs, your insurance company will want you to switch to that generic . . . which isn’t always a good option. I’ll show you what I mean.
The game changers:
1. Losartan, the generic Cozaar: Losartan was the first in its class of angiotensin receptor blockers (ARBs) to become generic making it a huge winner, yet making other brand name ARBs even more expensive. You will notice now that if you are on an expensive brand name ARB like Diovan, Micardis or Avapro, your insurance will want you to switch.
3. Levofloxacin, the generic Levaquin: This convenient once-a-day antibiotic was playing second fiddle to ciprofloxacin when it was an only available as an expensive brand name. It is now available in generic form as a once-a-day antibiotic for urinary infections, sinusitis, pneumonia, and bronchitis which is also good news for consumers.
4. Escitalopram, the generic Lexapro: This antidepressant was costing many folks a lot of money. Lexapro is/was popular because of its favorable side effect profile and its effectiveness for both depression and generalized anxiety disorder. Now, it’s generic.
5. Sumatriptan, the generic Imitrex: The first “triptan” migraine medicine to go generic was sumatriptan. Sumatriptan works well for migraines but tends to have more side effects than the other triptans. It’s good news that sumatriptan is available as a generic, but it will make insurance companies loathe to pay for Maxalt-MLT, Relpax, Amerge or Frova. So though they may work better for you than sumatriptan, they will cost big bucks.
6. Meloxicam, the generic Mobic: This anti-inflammatory is safer on the stomach than the NSAIDS and is called a Cox 2 inhibitor. Meloxicam is the first Cox 2 inhibitor to become generic, which will make Celebrex, the other Cox 2 player, way more expensive.
7. Pantoprazole, the generic Protonix: While omeprazole has been generic for a while, many GI doctors thought Protonix was more effective, and now it’s cheaper. That’s all good news except for those still taking brand names in this class like Nexium, Aciphex or Dexilant – now those will cost you an arm and a leg.
8. Zolpidem, the generic Ambien: Zolpidem was the first of the newer class of sleep medications to become generic, which was good news for consumers, unless you try to get Lunesta covered by your insurance which won’t easily happen now.
9. Fluticasone nasal spray, the generic Flonase: This was the first nasal steroid spray often prescribed for allergy symptoms to become generic. Again, this is great news unless you try to get Nasonex or Omnaris covered by your insurance plan.
10. Metaxalone, the generic Skelaxin: As we moved away from sedating muscle relaxants like Soma (carisoprodol) and Flexeril (cyclobenzaprine) Metaxalone was a popular non-sedating, non-narcotic muscle relaxant that used to cost people a ton. Now, it’s generic and cheaper, which is good.
The generic versions of the above medications are typically covered by insurance as Tier 1 medications, falling under your lowest co-pay. Where the brand names are still covered, they will likely be Tier 3 medications, meaning you will pay your maximum co-pay – and more often, they will not be covered at all. Generic prices range from $10- $15 per month for medications that are less expensive or have been available longer, like zolpidem or pantoprazole, to $75 – $100 per month for more costly medications like atorvastatin or metaxalone.
Daily use of Propecia for more than 3 months is necessary before benefits are observed, so it does work . . . but at a cost. Remember that continued use is recommended to sustain benefit and when you stop, you will see reversal of what Propecia did within 12 months. Ok now, think about the cost: Propecia is more than a dollar a day so you will be forking out more than 50 bucks a month. But wait, I have a secret for you.
Merck makes both Propecia (1 mg of finasteride) and Proscar (5 mg of finasteride). Proscar, unlike Propecia, is available as generic finasteride. If you can cut your finasteride tablet in three pieces, the difference in cost is striking. You can save a ton of money.
Is it worth it? Yes, Propecia (finasteride) works. In male pattern hair loss, the balding scalp contains increased amounts of DHT compared with hairy scalp. Finasteride decreases scalp and serum DHT concentrations (DHT is what testosterone is converted to).
Is there a downside to Propecia? Not really. In controlled trials of Propecia (finasteride) for the treatment of male pattern hair loss, discontinuation rates were similar to those taking placebo and decreased ejaculate volume was the main complaint.
Propecia is typically not covered by insurance, and costs about $70 – $75 per month. Merck, the manufacturer, also offers up to $60 off the first 90-day supply, and up to $200 off the fourth 90-day supply, for a savings of $260 in your first year. In contrast, finasteride is covered by most insurance plans as a Tier 1 medication – meaning you’ll pay only your lowest copay – and it can be found for as low as $10 – $20 per month.
Some of the newer popular birth control pills with a different type of progesterone are associated with an increased risk of blood clot in the leg. You need to care about this, not just because you have seen TV commercials and warning ads, but because a blood clot – deep venous thrombosis (DVT) – can break off and travel to the lung where it is called a pulmonary embolism. That can be fatal. There is also a question of increased risk of clots in arteries with these birth control pills, which can lead to cardiovascular events.
These are not huge risks and are still very rare, but here is what you need to know. Newer third-generation progestins may be associated with a greater risk of venous thromboembolism (DVT or deep venous thrombosis) when compared with older progestins.
In a study of 800,000 women, the use of combined contraceptives containing drospirenone was associated with a significantly higher risk of venous thrombosis compared with use of older combined hormonal contraceptive pills containing older progestins and similar low estrogen levels.
Examples of pills with the newer progestin (drospirenone) are Yaz (generics Gianvi, Loryna, and Syeda), Beyaz, and Yasmin (generics Ocella and Zarah) where you risk of clot in the leg is 5 times greater. What this means is that the risk of thromboembolism (clot in the leg) is higher when compared with levonorgestrel, a second generation progestin which is found in these birth control pills: Aviane, Lutera and Seasonique (generics Camrese and Amethia).
Remember, the risk is still small, though there is a two to threefold increased risk of clot in the leg (DVT) in those pills containing drospirenone compared with levonorgestrel. I certainly don’t think women taking an oral contraceptive containing drospirenone should stop their medication without consulting with their doctor, though it is worth a discussion.