Why hast thou forsaken me, United Healthcare?
June 7, 2013 1:39 PM   Subscribe

I just received a notification from my insurance company that as of July 1 they're no longer covering the brand-name version of a necessary medication I take daily. If I want to keep taking it I have to pay the full price (many hundreds of dollars per month)—or switch to the generic, which I've taken before and found that for me it is basically crap. It doesn't work as well, and has pretty unpleasant side effects, and I have documentation to that effect from my doctor of many years. Is there anything I can do to create a happy ending here?
posted by firstbest to Health & Fitness (19 answers total) 3 users marked this as a favorite
Do they want you to take a true generic (same chemical formula without the brand name) or do they want you to take a therapeutic substitution (different chemical formula that theoretically accomplishes the same thing -- but not in your case)?
posted by Longtime Listener at 1:45 PM on June 7, 2013 [2 favorites]

Your doctor may be able to tell the insurance company that the brand name is medically necessary, but I think whether they then have to reimburse you for the brand name depends on the insurance company's rules and possibly state law where you are. Your doctor would be the first person to talk to about this.
posted by MadamM at 1:47 PM on June 7, 2013

Yeah, talk ASAP to your doctor about what they can do in terms of submitting a letter or appeal on the basis of medical necessity.
posted by scody at 1:52 PM on June 7, 2013 [3 favorites]

I take two medicines several times a day or I will die. My insurance doesn't regularly cover them but they do at my doctor's request for medical necessity.
posted by munchingzombie at 1:57 PM on June 7, 2013

I'm with Longtime Listener. A true generic version would vary only in psychosomatic side effects.
posted by IAmBroom at 1:58 PM on June 7, 2013

Last year, the FDA found that the generic (Buproprion) is "not therapeutically equivalent" to the brand-name (Wellbutrin XL). Should've mentioned that! Sorry, so stressed about this that I'm not thinking straight.
posted by firstbest at 2:06 PM on June 7, 2013 [3 favorites]

Usually this is a matter of your doctor requesting a "prior authorization" for the brand name. Since you have a documented intolerance to the generic this should be pretty straightforward, although I've noticed an increased number of roadblocks of this sort (all examples are from this week):
1) I call to request a PA. The CSR tells me the patient no longer has medication coverage. I call the patient who confirms that they do. I call the insurance company again who tells me the PA was denied based on my call from the day before and I now have to submit a letter of appeal. I write and fax the letter of appeal and the patient gets the PA (for a year).
2) I call to request a PA, providing verbal documentation of why the medication is necessary. I get a fax back saying that it has been denied based on lack of documentation. I now have to submit a letter of appeal with the SAME INFORMATION. I write and fax the letter of appeal and the patient gets the PA (for a year).
3) I call to request a PA and the insurance company tells me that I now have to document failure of ALL generic equivalents (this is most relevant for things like proton pump inhibitors or statins where there are a lot of medications in the class).

It takes a while to make these requests and then it usually takes a few days for the official decision, so ask your MD to do it now so that when you need your July refill it isn't delayed. I get angry calls all the time because patients have waited until they have 2 pills left to tell me they need a PA, and they somehow think it's my fault that their insurance company wants 3 business days to make a decision.
posted by The Elusive Architeuthis at 2:09 PM on June 7, 2013 [4 favorites]

Wow! OK, firstbest - I guess Buproprion is not chemically identical to Wellbutrin XL after all.

Good to know; I am on ... well, the same meds.
posted by IAmBroom at 2:13 PM on June 7, 2013

Just so you're aware, the FDA found that a specific Wellbutrin generic (budeprion, sold by Teva pharmaceuticals) is not equivalent to the brand name. The other generics, which go by the name of bupropion, are as far as I know (and can tell, as I'm on this medication as well) still considered therapeutically equivalent.

Quoted from the article you linked: "This announcement relates only to Budeprion XL 300 mg manufactured by Impax and marketed by Teva. It does not affect the Impax/Teva Budeprion 150 mg product or generic bupropion products made by other manufacturers."
posted by krakenattack at 2:26 PM on June 7, 2013 [1 favorite]

This isn't to say that the other generics are the same as the brand name or even each other, your mileage/chemical makeup may vary etc, but have you tried generics other than Teva?

I believe this is an image of the Teva generic, so you can check if that's the one you found to be ineffective.
posted by krakenattack at 2:30 PM on June 7, 2013

Every state has an insurance commission, they may be able to help you find a way to get the medication you need.
posted by theora55 at 2:42 PM on June 7, 2013

A- You're not kidding, brand name Wellbutrin XL is expensive.

B- I too noticed that the generic did not work as well. Part of the problem is that the method to make the product extended release is a patented husk kind of thing, and while the active ingredient (buproprion) is likely the same, the drug does not get released in the same way. (Basically, the shell that the drug is contained in does not melt and get digested. Instead, it absorbs water and increases osmotic pressure inside it which slowly leaches out the drug over the course of 24 hours. But the generic stuff works some other way.)

C- What you might try is switching to a twice daily SR version, or the thrice (I think) daily plain old regular buproprion.
posted by gjc at 2:43 PM on June 7, 2013

I take generic bupropion. I've taken the Teva generic (known as "budeprion") and... yeah, didn't really work so good. It seemed like only the 300 mg version (the yellowish oblong pill) was a dud; the 150 mg budeprion worked fine. The affected dose of budeprion has been pulled off the market, so it's probably no problem at all.

I forget who makes the generic I currently take, but it's not Teva. The pills are round, white, and have a pleasant almost matte-plasticky surface. I like them quite a bit.

If the dud budeprion is back on the market for some reason, your potential solutions are: call around and find a pharmacy that carries a Wellbutrin XL generic that isn't budeprion, or have your doctor write a script for two 150s instead of one 300, if your insurance will cover that.
posted by Metroid Baby at 2:46 PM on June 7, 2013

Call member services; go through the prior auth process: I'm assuming you need a DAW difference waiver. Have your doctor fill out all the forms required by insurance and am FDA medwatch fprm(ask if its needed). Ask if they required the names of the manufactures you've failed: if so get them from your pharmacy and tell your doctor.

Now if your benefit doesn't alot for a DAW waiver, ask for a copayment exception or a medical necessity PA.

If your PA is denied: appeal, appeal, appeal.

If you get a rep from member services that seems like they don't care or have no idea what their doing; ask for a supervisor. Please please be nice to the rep and they should be going out of their way to help you!

If nothing works, find another insurance.

Also look to see if the brand manufacture offers assistance in paying for your medication (coupon/copay card)
posted by Bun Surnt at 3:00 PM on June 7, 2013

Your results may vary based on Pharmacist and Insurance Reps, but show your pharmacist the documentation from your doctor, and ask him/her to call the insurance company to set up an exemption/waiver.
posted by 1367 at 4:04 PM on June 7, 2013

I had the same problem, same medication, and no luck getting the insurance company to pay for the brand name version, even when my doctor jumped through hoops for me. Eventually I found one generic brand that worked okay (Watson Labs). I have had to switch pharmacies twice to chase it (first to Costco, now to Target). I guess for this medication manufacturers are always undercutting each other with shittier product or something. It's pretty ridiculous how bad some of them are. I understand what you are going through. I think it took a bit of time to adjust to the Watson Labs version - I felt like I was sinking and then evened out and decided to stick with that brand.

My insurance doesn't work with Target, so I pay out-of-pocket and I think the retail price is about $40 but they got me hooked up with some kind of discount card thing so it's more like $31. I can submit my receipts for reimbursement afterwards but they only gave me like $3 each when I did that (still, time to do it again, I have a tight budget and it will help). If you get the Target Red Card it knocks 5% off the price, as well. I use the debit card version of the Red Card so I am not having to deal with a credit card balance I have to pay off later. In addition, after filling 5-6 prescriptions they mail me a 5% off card to be used for all Target purchases on one day. The discounts stack.

Good luck, I know how rough this is.
posted by marble at 8:26 PM on June 7, 2013

It turns out that generic drugs often have different effects than the same name-brand drug.
posted by raf at 1:10 PM on June 8, 2013

Assuming you're in the United States, a surprising option may be comparison shopping. Make some phone calls and ask around.

There are differences of hundreds of dollars between competing pharmacies for identical prescriptions. I was really shocked at this, so I think I'm not alone. I would never have thought that Americans as a society would be willing to regulate via legislation the price of milk and gas but not pharmaceuticals.

I may sound like a shill at this point but Costco in particular has striking discounts on pharmaceuticals in my experience, due to their insistence on marking items up no more than 15%.
posted by hobo gitano de queretaro at 2:46 PM on June 8, 2013

A big thank-you to firstbest for this thread, which corrected my delusion that "generic" drugs were chemically identical.
posted by IAmBroom at 10:48 AM on June 11, 2013

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