Penny Wise, Pound Foolish

A patient of mine has been on cyclobenzaprine, a muscle relaxer, intermittently for over a year. Now her insurance, a Humana, Medicare plan, said they will no longer cover it. I pointed out to them that the medication is generic and at Costco one could purchase 100 pills for $9.93 without insurance. That would be enough to last her over 3 months. The Costco price for tizanidine they suggested I switch her to costs even more. They told me to check their website for what they cover, which I did. It said cyclobenzaprine is covered, though on some of their plans it requires prior authorization, which is what I tried to obtain. Besides the risk of switching a medication to something new, Humana wasted the time of my nurse and I for what would be a minuscule, if any savings. They would not budge other than saying she had to first try and fail tizanidine.

I understand the need to control costs, but forcing doctors to change from one cheap medication to another cheap one is not the way to do it. It doesn’t save significant amount of money, and it frustrates their customers (the patients) and their physicians.

Insurance companies such as Humana place no value on physicians time. I hope other physicians join me contesting such things from time to time. Don’t just accept the first no. Make them deal with extra phone calls and faxes when they are unreasonable. If enough of us protested, I think we could force them to change their ways. Occupy Medical Insurance Companies Movement, anyone?

Author: Daniel Ginsberg, MD, FACP

I'm an internal medicine physician and have avidly applied computers to medicine since 1986, when I wrote my first medically oriented computer programs. So yes, that means I'm at least 35-years-old!

2 thoughts on “Penny Wise, Pound Foolish”

  1. Dear Dr. Ginsberg,
    I’ve read your blogs about Humana and their dealings and find them quite interesting. Here is another one for you. I would appreciate your comments.

    On January 29, 2013 our pediatric neurologist ordered 210 tables of 25mg Topamax for my 14 year old daughter and her three weeks of migraine headaches.

    When I got to the pharmacy I had to wait while the pharmacist tried to deal with the computer message returned by Argus, the Humana, electronic claims processor. The message returned by Argus said: “use appropriate tab or cap strength.” After a 30 minute on the telephone the Pharmacist still wasn’t certain what the message meant.

    I took out my cell phone and called Humana. The message meant Quantity Limitations. Humana decided my daughter should get 90 tabs over a 30 day period. I asked why? I was told that Humana uses a Pharmacy Review Board to set the dosages for medications based upon recommendations by the FDA and Drug Manufacturer.

    The next day I called the FDA and Janssen Pharmaceuticals. Both of them disagreed with Humana over the phone and with a PDF document on their website. There are multiple conditions treated by Topamax, we don’t recommend 25 mg three times a day for any condition. We recommend you FOLLOW YOUR DOCTORS ADVICE.

    I called Humana repeatedly. I didn’t care about the usage limits. They are in business to make money. Don’t lie to me. Just tell me you are using quantity limits to save money. But they stuck to their guns, and tell me it is for the best of the patient. Good thing I have such a good physician.

    1. Without knowing all the details it’s hard to say. I’m not sure about pediatric doses, but the adult dose of Topamax for migraines is 100 mg per day. If he prescribed her to take 25 mg 3 times a day, that would be 90 pills a month, or 270 in 3 months. Whether he was prescribing for a 1 month or 3 month supply, I don’t see how he came up with 210 (assuming it wasn’t really 270 and they misread the “7” for a “1”), unless he wrote for less because she would be starting at a lower dose and gradually increasing.

      I think it does make sense for insurance companies to put reasonable limits on the amount described. For one thing, it can prevent errors. Suppose the neurologist accidentally wrote to take 3 pills a day with meals. He may have meant take 1 pill with each meal, but it could be interpreted to take 3 pills with each meal. Having a quantity limit may catch such errors. It also makes sense due to cost. Some medications cost the same no matter what strength. So taking two 25 mg pills twice a day would cost twice the price of taking one 50 mg pill twice a day. Physicians are not always aware of such things, and the limit may save a lot of money without doing any harm.

      That said, there are plenty of times where the insurance companies are just trying to nickle and dime their customers. Generic Topamax (topiramate) is fairly cheap. Safeway, for example, sells 180 of the 25 mg pills for less than $16. Cut the 50 mg pills in half and you cut the price to $11. Make the mistake of ordering the capsules instead of the tablets and it will cost you about $108 for the same amount.

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