After practicing medicine for 20 years, I’ve become adept at “clarifying” to insurance companies why patients are taking certain medications. The same medications appear to trigger red flags for both long-term care and life insurance companies.
Their “concern” makes sense for some medications because they are used for serious chronic illnesses, but for others, the insurance companies are worried about your lifestyle. Most on this list are important medications so do not stop taking them because you’re concerned about rejection and do not omit them from your forms. Instead, along with your physician, you can clarify and appeal their decision.
Here are the ten worst medications to be taking that will trigger a “no” or a further review if applying for life insurance or long-term care insurance.
- Namenda (memantine) or Aricept (donepezil). One of the more obvious red flags, dementia is expensive for Long-term care insurance plans because folks with dementia are often physically healthy and their care is expensive. Pro tip: be careful here because Namenda is also prescribed for migraine prevention and may trigger an unnecessary alarm.
- Hydrocodone, oxycodone, morphine aka “Opioids.” Long-term use of pain medication raises red flags for insurance companies and almost always results in a closer review. Why? Because costs associated with chronic pain patients taking opioids are substantial and range from 560 to 635 billion per year in the U.S. in 2010. Insurance companies run for the hills because of that.
- Xanax (alprazolam), Ativan (lorazepam) and Valium (diazepam) are benzodiazepines that will lead to a closer review of your application. Why? Several studies have shown an association between benzodiazepines and risk of death. In folks 65 years or older benzodiazepines increase the risk of falls and fracture-related mortality. Some studies have found a threefold or higher increase in the risk of all-cause mortality among adult populations using benzodiazepines even for durations shorter than one month.
- Lithium and Divalproex. Life insurance companies love to hate bipolar medications because suicide rates in bipolar patients average approximately 1% annually, or 60 times higher than the international population rate. Pro tip: If you take Valproic acid for migraine prevention or trigeminal neuralgia you will want to clarify if turned away.
- Paxil (paroxetine), Lexapro (escitalopram), Celexa (citalopram), Zoloft (sertraline) aka the “SSRI” antidepressant medications. This is one of the common reasons my patients are turned away, and yes you can appeal and clarify this. Why are life insurance and long-term care insurance plans worried? Because of the risk of suicide and increased use of healthcare resources in folks with depression and anxiety.
- Plavix (clopidogrel). This is another common medication that will often lead to a “no”. Clopidogrel is used for the treatment of coronary artery disease and atherosclerosis – often given to patients who have had stent placement for coronary artery disease. This puts you in a high-risk category and insurance companies don’t like that.
- Arimidex (anastrozole) or tamoxifen. These are medications taken long term to prevent the recurrence of breast cancer. Even though cancer outcomes have been improving dramatically in recent years, life insurance companies continue to see cancer as a high-risk situation. Breast cancer receives quite a bit of scrutiny from insurance companies.
- Naltrexone, Campral or Antabuse (disulfiram) are medications used for the treatment of alcohol abuse and that sends insurance companies running for the hills. Insurance companies don’t like alcohol overuse or abuse to be part of your history and this medication is used to help with alcohol cravings and will trigger a red flag.
- Harvoni, Sovaldi, and Viekira Pak. Medications used for the treatment of Hepatitis C will cause insurance companies to balk at your application. Pro Tip: Here is a perfect example of where you can file an appeal and have your doctor help with clarification especially if you have achieved cure (sustained virologic response) of your Hepatitis C.
- Atripla and Genvoya are commonly prescribed combination HIV medications and will often trigger a “no” for long-term care and life insurance policies.
Has this happened to you?
More and more women across the U.S. can now use hormonal birth control without going through the hassle of having a doctor prescribe it.
7 states – Oregon, California, Colorado, Washington, New Mexico, Hawaii, Tennessee, and Maryland – and Washington, D.C. now allow pharmacists to prescribe birth control, saving women a trip to the doctor’s office. California, Maryland, and D.C. ensure residents get full access to contraception by also providing a 12-month supply at a time and requiring insurers to cover the entire cost. (Women in Illinois and Vermont also can get a 12-month supply paid by insurers, but only with a doctor’s prescription).
How does it work? What do I do to get a prescription?
- Call your pharmacy to see if they offer the birth control prescription service. If not, you may have to call around to find one that does.
- When you get to the pharmacy, you’ll be given a short screening questionnaire and have your blood pressure taken to make sure hormonal contraception is appropriate for you. Trained pharmacists will know the pharmacology and screening procedures, and will know how to assess which method is best for each individual, so you’ll be in good hands.
- Your pharmacist will work with you to find a brand you can afford, with or without insurance. Refer to our explainer on birth control pills to understand all your options. In some cases, GoodRx can beat your insurance, and you can always use a GoodRx discount instead of your prescription insurance if the cost is lower.
What does this mean for me, specifically?
If you live in Oregon, California, Colorado, Washington, New Mexico or Hawaii, your state law is already in effect. Check the map below (thanks to the Kaiser Family Foundation) to see what type of birth control pharmacist in your state can prescribe. At the minimum, they can recommend and prescribe birth control pills, which have a 9% failure rate with typical use (compared to the 18% failure rate of condoms). California is currently the only state where women can receive a whole year’s supply in one visit.
If you live in D.C., Tennessee or Maryland, expect pharmacy programs to start rolling out as early as January 2019. We’ll report here on the GoodRx blog as we get more information.
What’s the catch?
Making birth control easier to access should encourage more women to get protection. In a 2013 study, 28.0% of participants not using any birth control and 32.7% of participants using a less effective method said they would use oral contraceptives pills if they were available over-the-counter. While the current laws don’t quite make birth control over-the-counter, they do mean women who would otherwise be restricted by work hours, child care, transportation, and money will have more options.
But even though these laws are in place, the service is not mandatory for pharmacies. Researchers found that only 11% of California retail pharmacies offer the service, one year after the law was put into effect. Requirements vary by state but they all require at least some training, so not every pharmacy can automatically offer the service. To see the larger impact legislatures and supporters hope for, more pharmacies would have to get on board. For example, Safeway is the first major retailer in Colorado dedicated to training their pharmacy staff.
One last thing: It’s not free. Pharmacies that do offer the prescription service typically charge between $25-$50. Because the Affordable Care Act only requires insurers to cover family planning services from healthcare providers, women would have to bear the full cost of the pharmacy consultation themselves; some may not be able to. Some states are making moves to change this: Oregon requires Medicaid to pay for the service, while California is hoping to do the same by 2021.
More than one in ten visits to a primary care doctor is for fatigue. Fatigue is composed of three major components: generalized weakness (difficulty in initiating activities), easy fatigability (difficulty in completing activities), and mental fatigue (difficulty with concentration and memory). While certainly not the only answer, medications may cause fatigue. Here are some of the common culprits.
Beta-blockers wear many hats. They are commonly prescribed to improve survivability after a heart attack, lower blood pressure, help prevent a migraine headache, and control heart rate in atrial fibrillation. But, there is a downside. They can make you sleepy.
Carvedilol (Coreg), atenolol and metoprolol are common offenders when it comes to fatigue, occurring in more than 10% of people taking them. In fact, a quarter to half of the folks taking beta blockers discontinue their use during the first year of taking them, often for fatigue.
Pro tip, starting at low doses and titrating up will help with the fatigue so lower doses of beta blocker, increasing over time, is the way to go.
These are medications used for allergies, hives, nasal congestion, and itchy rashes. Benadryl, Atarax and cyproheptadine are all very sedating, and most available over-the-counter. Over the counter meds ending in ‘pm’ like Tylenol PM contain Benadryl and of course will cause drowsiness.
Many folks taking muscle relaxants for back or neck pain have no idea these may make them feel like Gumby for a few days. Commonly prescribed muscle relaxants cyclobenzaprine, Soma (carisoprodol) and Zanaflex (tizanidine) are hugely sedating.
Amitriptyline and Nortriptyline are also used to treat depression, chronic pain, and migraine and cause drowsiness and fatigue. In some studies, up to 40% of folks taking these two reported fatigue. That’s high.
Another good option? Studies have shown that bupropion SR and XL (Wellbutrin XL) are just as effective as SSRIs for the remission of major depressive symptoms. Those taking bupropion are less likely to suffer symptoms of sleepiness and fatigue than those treated with SSRIs.
Topiramate causes drowsiness and fatigue in up to 15% of people using it. Commonly used for prevention of seizures, migraine headache and weight loss (Qsymia contains topiramate), Topamax carried the nickname Dopamax because those taking it may feel ‘dopey.’
And last but not least
- Narcotics like hydrocodone, oxycodone, and acetaminophen/codeine may make you sleepy.
- Benzodiazepines like Ativan (lorazepam), Valium (diazepam) and Xanax (alprazolam) often cause you to feel sleepy.
Pattern of Adverse Drug Reactions Reported with Cardiovascular Drugs in a Tertiary Care Teaching Hospital. J Clin Diagn Res. 2015 Nov;9(11)
Discontinuation of beta-blockers in cardiovascular disease: UK primary care cohort study. International Journal of Cardiology Vol 167 (6) 10 Sept 2012 pages 2695-2699.
Prescription opioids like oxycodone, hydrocodone, codeine, and morphine have long been considered some of the most helpful drugs for managing acute pain, where the body is immediately reacting to trauma or injury. Each year, over 200 million opioid prescriptions are given out in the United States.
Unfortunately, the rates of opioid abuse and overdose deaths have skyrocketed in recent years, leading healthcare providers and patients alike to be cautious about the use of opioids. And now it turns out that there is another reason to avoid opioids: they may not be the most effective treatment for acute pain after all.
Do opioids work better than other drugs?
A recent study in the Journal of the American Medical Association throws into question how well opioid drugs actually treat acute pain.
In the study, researchers assigned 416 emergency room patients with moderate-to-severe pain to one of four treatment groups. Three of the treatment groups received a combination of a common opioid painkiller (either oxycodone, hydrocodone, or codeine) plus 300 mg of acetaminophen, a common non-opioid pain medication often sold over the counter as Tylenol. The fourth group received 400 mg of ibuprofen, a non-opioid painkiller, plus 1,000 mg of acetaminophen.
The result? All four groups experienced the same levels of pain relief. While opioid drugs did help to reduce pain, they were no more effective than a combination of non-opioid painkillers.
What are other options for pain treatment?
While opioids are usually given for acute pain, some of the following options also work well for chronic pain, or pain that lasts longer than six months.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen, naproxen, and aspirin are known as nonsteroidal anti-inflammatory drugs (NSAIDs). They control pain, lower fevers, and reduce inflammation. NSAIDs are often considered to be the first line of defense for acute pain, especially pain that doesn’t respond to non-drug treatments.
NSAIDs are available over-the-counter with brand names including Advil, Motrin, Aleve, Bayer, and Excedrin. NSAIDs are also available in prescription strength, with common brand names like Celebrex, Naprelan, Anaprox, Voltaren, and Feldene.
One word of caution: long-term use of NSAIDs can lead to stomach distress or bleeding in your gastrointestinal tract, and the FDA warns that non-aspirin NSAIDs may increase the risk of heart disease and stroke.
Acetaminophen is used on its own as a painkiller and is also an active ingredient in many combination medicines for pain and colds. It is a popular over-the-counter option, sold under brand names like Tylenol. Acetaminophen is especially helpful in addressing acute pain for conditions like headache, arthritis, and cancer pain.
Acetaminophen does not cause the gastrointestinal or cardiovascular side effects of NSAIDs, but taking amounts in excess of the recommended dosage may lead to liver damage or even liver failure. Because acetaminophen is present in so many medications, check whether other medications you’re taking contain acetaminophen as well.
A category of antidepressants called tricyclic antidepressants have the most evidence for treating pain, especially nerve pain. Imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin), and amitryptiline (Elavil) are tricyclic antidepressants. While these drugs can be helpful, they aren’t effective for everyone.
Some evidence shows that two other categories of antidepressants–selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), or serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta)–are also helpful for chronic pain, but more research is needed.
Anti-epileptics can be taken to address chronic nerve pain and chronic pain from conditions like diabetes, shingles, chemotherapy, herniated disks, and fibromyalgia. Research on how well anti-epileptic medications work for pain is unclear. Some people may receive significant benefits while others may not receive any pain relief at all.
Newer anti-epileptic drugs such as gabapentin (Neurontin), and pregabalin (Lyrica) have more evidence of being effective painkillers than older drugs, and they carry fewer side effects. But, some studies have shown that older antiepileptic drugs such as carbamazepine (Tegretol) and phenytoin (Dilantin) can also help for certain pain conditions. However, these older medications cause more side effects.
Corticosteriods, commonly referred to as just steroids, decrease inflammation and reduce the activity of the immune system. They can reduce swelling and pain for conditions like cancer, back injuries, arthritis, joint pain, and nerve pain. Steroids can be helpful for short-term treatment of acute pain and are also used for the management of some chronic pain conditions., Common steroids used for pain relief are dexamethasone (DexPak), prednisone (Deltasone), and prednisolone (Prelone).
Steroids can be taken orally, applied as a cream, injected, or inhaled. Steroids do come with side effects such as weight gain, high blood pressure, and weakened immune system. Taking low doses of steroids for short periods can minimize those side effects. Injecting steroids directly into an area of pain also reduces side effects and promotes targeted treatment of the affected area.
Non-drug treatments like exercise, physical therapy, yoga, acupuncture, cognitive behavioral therapy, biofeedback, chiropractic, and relaxation training can provide pain relief, especially for chronic pain., In fact, organizations as diverse as the American College of Physicians, the U.S. Department of Veterans Affairs, and the Centers for Disease Control and Prevention recommend non-drug treatments as the first course of action for chronic pain. Although side effects for non-drug treatments tend to be minimal, be sure to consult with a healthcare provider before beginning any new treatment activities.
It’s the beginning of the school year, which means that it is time to prepare for the little bugs that get passed around the classroom, lice!
Head lice are parasitic insects that can be found on the head, eyebrows, and eyelashes. Preschool and elementary school-aged children, as well as their parents and caregivers, are at the greatest risk for lice infestation. The most common way to spread lice is through head-to-head contact, which can easily happen when children are playing.
Here are some tips from the pharmacist to help prevent and treat head lice.
Try over the counter options first
There are over the counter (OTC) options that can be used if your child has lice. OTC items like Nix are available at your local grocery store. Using an OTC option first can save you money, as many of the prescription-only items can be costly, and may not be covered by your insurance.
Prescription treatment is available
If you’re unable to get rid of lice using OTC products, your doctor can write you a prescription for lice treatment. The following are examples of prescription-only lice treatment.
- Sklice is for children 6 months of age and older. It is a 10-minute treatment that doesn’t require any nit combing. The manufacturer offers a savings program that can reduce your co-pay to at least $30. For more information, visit their website here.
- Ovide is a lotion used on children 6 years of age and older. Keep in mind that it is flammable, and a second treatment may be required after seven days if lice are still present.
- Ulesfia is for children 6 months of age and older. Be sure to repeat the treatment after seven days. The manufacturer offers a savings program that can reduce your co-pay to as little as $10. For more information, visit their website here.
- Natroba is a topical solution indicated for children 6 months of age and older. Nit combing is not required, but using a fine-tooth comb may be helpful to remove dead lice and nits.
Don’t share personal items
Teaching your child to share is an important life lesson; however, some personal items should not be shared in order to protect against spreading lice. Make sure your child knows that personal items like brushes, hats, helmets, headbands, and towels should not be shared.
Check with your state department of health
Each state department will have information on symptoms, treatments, and guidance for lice prevention and treatment. Refer to your state’s department of health website for more information.