Insurance Reimbursement for Brand Name Medications

We all know how important it is to receive a consistent dose and uniform quality of medication when embarking upon Antibiotic Protocol (AP). Even if your physician writes "DAW" (Dispense As Written) in the box on the bottom of the prescription form, you may learn this is not always sufficient to ensure your being given the brand name or obtaining coverage for its cost. Neither does the physician's writing that the brand name is "medically necessary" on the prescription guarantee compensation, although both are a good start and should be indicated on your "Rx script." Every insurance company has its own guidelines for which medications it will allow its policy holders to get as a first option, and it is likely that you may need to appeal these regulations to get reimbursement for the brand name. Where do you begin?

You, or in some cases your doctor, will have to call your insurance company and ask for the "generic appeal program" forms. One woman reported calling her insurance carrier and being told that they could not send her a form until she failed using the generic. The determined patient immediately went into her battle mode and said "Fail...as in end up really sick? Or perhaps you mean fail as in end up in the hospital? Maybe that will be more cost effective!" The surprised clerk was happy to pass the phone call along to her superior who ultimately did supply the form.

Once you receive the form, it may contain an area for your physician to fill out, including a statement about the medical necessity of the particular brand name. Or, as some have reported, it could mean "building a case."

The following are some ideas others have shared that you may find pertinent to your situation. You could incorporate any of these in the letter to your insurance company.

• Generics are allowed to vary in percentage of active ingredient by plus or minus 20% as compared to the brand name (either 20% more or 20% less). That means they could vary from one version of generic to another by 40%. This could make the difference between success or failure of low dose therapy, especially if you are "pulse" dosing (eg: taking your medication on Monday, Wednesday, Friday)

• Many generics contain lactose as the filler. If you are lactose intolerant, you might want to learn before hand about the "inactive ingredients" that comprise the "inert fillers" in the medication your pharmacy is offering you as a generic. Ask your pharmacist or check a Physician's Desk Reference (PDR) at your library or online. Pharmacies order from various distributors and they dispense the generics a particular supplier carries. Therefore, different pharmacies may fill your prescription with different generics. Indeed, you could end up with a different generic even at the same pharmacy if they simply change distributors. Be aware that some brand name medications also contain lactose.

• Generics may contain a variety of other ingredients as fillers and colorings. Patients with sensitivities to those substances can encounter problems when taking the generic. Have that information available. Know exactly what is in the brand name of the same drug so that you can argue your point. For example, Minocin, the brand name minocycline by Triax pharmaceutical company contains the active ingredient and only cellulose as the filler.

• The brand names that are pelleted are time released and said to be gentler on the stomach and better absorbed. Those qualities help to maximize the efficacy of the medication. For example, Doryx, produced by Warner Chilcott, is a brand name of doxycycline that people with some gastrointestinal problems have reported they tolerated well. However, it does contain lactose and may no longer be readily available in capsule form

  Minocin is pelleted and significant numbers of patients report it is both more easily tolerated and appears to be more effective than many generics.

• Some medications now offered for rheumatic disease are very costly. If you are presently on any of the newer, more expensive agents, do a comparison of the cost of that drug with the antibiotic for the insurance company to consider. Explain that after a period of time on AP, patients can usually wean off the more expensive medications. You can also indicate that AP is safer and causes few if any side effects. Then, you can cite some of the side effects listed for the more toxic medications that are conventionally used. If you are not on those drugs, it is a very good argument that you may be able to avoid them and their cost to the insurance company.

• The Arthritis Foundation has listed minocycline as a DMARD (Disease Modifying Anti Rheumatic Drug). Minocin is listed as the brand name drug of that category.

• Clinical trials for rheumatoid arthritis (RA) and scleroderma(SD) were performed using the brand name Minocin.

• If you have an illness that has not yet been the subject of a clinical trial with antibiotic therapy, there is still a precedent for using the medication for your particular condition. Many of the drugs used in clinical trials for RA, for example, were later prescribed for additional rheumatic diseases. Methotrexate is now offered for lupus and other rheumatological conditions as are the anti TNF (Tumor Necrosing Factor) drugs such as Enbrel and Remicade.

• It is not necessary to test positive for mycoplasma to receive AP from your practitioner. However, if you have had either a positive mycoplasma complement fixation (MCF) test or PCR (polymerase chain reaction) test, getting the antibiotic of choice approved may be easier. One of the issues to be aware of with the MCF test is that it can give a false negative if used before the patient is on AP and it may not be sensitive to all strains of mycoplasma. Notably, even a low titer may be significant. PCR is more accurate but costlier and you need a month-long "washout" period of not being on antibiotics before you can use it. Alternatively, PCR can be performed before any antibiotics are taken. It is very important that you have these tests done by labs which specialize in them and that the blood samples are handled properly. Additionally, The Road Back web site has a listing of research articles that implicate an infectious component to various rheumatic diseases. Citing such literature may help support your argument.

• If you are already on AP and have successfully weaned from some of your other medications, have your pharmacy print out a list of all the medications you have taken for the past few years. The tabulation will indicate those that were not continued because refills will not be listed. It may also help you receive reimbursement for the money you have already spent on the brand name, if that is the policy of your insurance company. Your pharmacist should sign the list that you are submitting.

• Be sure to send your letter and forms to the insurance company by certified mail with return receipt requested. Retain photocopies of everything for your files.

If the appeal does not go in your favor, you could inquire at to whether your state has an Insurance Department that will intervene as your advocate( it may be under the Consumer Service Bureau.) Lastly, you can enlist the help of an attorney. Since AP is long term therapy, the cost of legal assistance may quickly be recouped if the expense of the brand name medication is reimbursed.

The Road Back Foundation does not engage in the practice of medicine. Consult with a physician to assess any medical treatment that is being considered. The Road Back Foundation encourages healthcare consumers to thoroughly investigate and understand all treatments and medications before proceeding. This material is for educational purposes only.

The Road Back Foundation
PO Box 410184
Cambridge, MA 02141
www.roadback.org