The “WHAT AM I THINKING” Game: Not fun at all.
Every doctor in Primary Care knows this game. Here is one example:
Albuterol inhalers:
Your patient is having an asthma attack and needs an “Emergency Inhaler” to supplement their care regimen. Which do you pick?
Here are the rules: If you pick the wrong one, the patient’s insurance does not cover it and the patient leaves the pharmacy empty handed until you, the doctor, figure out what went wrong. Are albuterol inhalers life saving? I would say YES. If Albuterol is withheld from patients, might they, at the very least, end up in the Emergency Room? Of course!
Okay… Here are your choices:
ProAir
Proventil
Ventolin
Pick the right one of these three and your patient lives.
Oops! There are some more choices:
Ventolin HFA
Accuneb
ProAir Digihaler
ProAir Respiclick
ReliOn Ventolin HFA
Maybe none of these are covered and the correct answer is Xopenex!
Now the odds of choosing correctly just went to one out of nine. Which do I pick?
Remember, the rules are that the pharmacist cannot and will not assist you in any way. Why? I don’t know, but it apparently involves a ton of time consuming work on their end. The pharmacist is also not allowed to substitute the covered inhaler because… Why? I really, really don’t know.
Work around: You create a pharmacy template: “Albuterol HFA MDI (any brand is okay).” Sometimes, this works. Sometimes not. Do you feel lucky?
More recently, lung disease patients with chronic inhalers face another dilemma: Advair. Is it covered? Maybe not and you have to order the generic equivalent, by name, Wixela. Again, you can’t choose both. In fact, you may have to choose a third inhaler that you never even thought about.
Isn’t this fun?!?
Name your own examples!
What fun! UHC just changed my preferred asthma med from Wixela to Advair. I’m enjoying trying to contact my large-group PCP to try to contact the on-line OptumRx pharmacy to make the change. It’s not like I have anything else to do. GoodRx price is over $120.
So here comes the troubling issue of politics mixing with pharma companies. I will try not to make this a political spectrum comment, but it’s very clear Al Gore took a whole lot of money from Pharma and was able to get banned chlorofluorocarbons-based inhalers, giving patent protection to three companies, Proventil, Ventolin, and proair. They had been about $17 an inhaler, they instantly went to well above 60 probably closer to 80 in most circumstances, and now that even the HFA inhalers are generic again proair isn’t even being made, they simply stopped. They had gotten their investment’s worth. It is obvious and clear that inhalers were not causing the hole in the ozone layer, but it was an expedient excuse for money. The generic works fine. In Texas we have generic substitution, so it doesn’t matter which of the meds I write, the pharmacist has the ability to substitute .
Everyone now knows it’s moose (mooses?) causing climate change. Those pesky moose farts!
So aggravating!!! Ever feel like you practice insurance instead of medicine?
I’d usually do the last choice: “Albuterol HFA 2 puffs q 4-6 hrs as needed (okay to substitute equivalent brand covered by insurance)”.
Not sure how much these inhalers are now, they used to be terribly expensive. I’d have patients fly to Spain or wherever to get it cheaper – and no rx needed!