We are now in 2018. Dr. Sobel and I routinely prescribe generic drugs whenever they are available. Why? Because they are equivalent in effect and safety, and they are often substantially if not vastly less expensive.
Generics Are the Equal of Brand Names
The question of the efficacy of generic or non-name brand drugs is long settled. The day of ineffective generics with poorly made pills that didn’t dissolve was left behind well back in the prior century. Generic drugs must meet the same purity, absorption and efficacy standards as the brand-name originals, and are tested and certified through the Food and Drug Administration to be fully interchangeable.
Most all drugs are safe and pure. Occasional failures show up in both in generics and brand name products. For example, prominent manufacturing failures I remember include brand name Synthroid (for underactive thyroid) in 2001, Tylenol brand in 2011, and currently generic valsartan (a drug for high blood pressure).
Brand Names When No Alternative
The most common reason to require a brand-name drug is when it is new, an improvement, and under patent. At that time there simply are no generics, and the availability is largely limited by the drug intermediary formulary and the usually unbelievable cost of the drug. When generics become available, we always prescribe them, again because of lower cost and comparable quality.
Prior Authorization Is Onerous
If we attempt to prescribe a brand-name when a generic is available, the prescription will almost always be subject to prior authorization by the drug intermediary. This is an onerous and time-consuming process in which our staff are required to answer a list of changing questions and are supposed to provide some concrete reason why the brand name is required and the generic insufficient or unsafe. If we do not have a supportable reason, the request is denied. Even if occasionally accepted, the patient price for the brand name is often exceedingly expensive and far higher than the patient ever imagined it could be, at which point the patient often says, “Oh, never mind.”
Patient Must Document Need for Brand
In essence, requesting prior authorization for brand-name drugs is a loser, and one that requires a large expenditure of our professional nurses time that diverts them from direct patient care activities that benefit our members. So in general we are not going to attempt to get such approvals.
The only exception that rarely arises is when a member tells us of unusual reactions that they experienced with the generic version of an important drug but not with the brand name, in a setting where there are not logical alternative drugs to use. If that is a solid and reproducible occurrence, and the patient will produce a short written description of adverse effects or lack of efficacy they experienced (dates, effects, resolution, etc.) with the generic that had not occurred with the brand name, then we can attempt to get a prior authorization approved so the drug intermediary will pay a substantial part of the cost, as they should.
Brand Names by Self Pay and Canada
The other variations are that we have no objection to writing for a brand name version of a drug that is appropriate for a patient, with the understanding the patient will pay for it out of pocket. And we are normally supportive of sending prescriptions to Canadian pharmacies (see post from January 2018) where brand names are available (but not controlled drugs) and are often dramatically cheaper.
Summary
In sum, our pharmaceutical system is vastly more complicated and expensive than it should be. This is our guidance as to how best to meet each person’s medical needs, obtain appropriate effective drugs, and give clear understanding why we prescribe generic drugs and why brand-name drugs are rarely medically necessary and do not usually justify investing our nursing time in fruitless attempts to achieve prior authorizations.
