Why was I given a different drug than what was prescribed?
If you’ve read our past blogs, you know that the drug market in the U.S. is a very complicated “enigma.” With many moving pieces affecting price, different pharmacies competing with each other and manufacturers looking for the next best drug, things can get a little murky to say the least. One recent scenario that came up was this: “I went to fill a script for a brand name drug but was given the generic version, even though the script was for the brand name! What gives?!?”
There could be a couple of things that would cause this to happen. We’ll take a look at a few possible scenarios and explain what each one could result in. We are going to look at this in relation to Rhode Island so you might have to do a little research to see if the same rules apply in your state.
First, let’s look at what actually happened in the example given in the first paragraph of this post. “Why was I given a generic drug when the brand name was prescribed?” In this case it was because the script was not written EXPRESSLY for the brand name drug. It’s actually a state mandate in Rhode Island that pharmacists must fill the generic version of a drug if available, unless clearly stated by the doctor or individual that the brand name only should be dispensed.
1.5.18Generic Substitutions
A. Pharmacists when dispensing a prescription shall, unless requested otherwise by the individual presenting the prescription in writing, substitute drugs containing all the same active chemical ingredients of the same strength, quantity, and dosage form as the drug requested by the prescriber from approved prescription drug products in accordance with the provisions of R.I. Gen. Laws §§ 21-31-16 and 21-31-15(l)(1), unless ordered by the prescribing physician to dispense as brand name necessary on the prescription form, or if the prescriber gives oral direction to that effect to the dispensing pharmacist.
216-40-15 R.I. Code R. § 1.5
Typically generic drugs are cheaper than their brand name counterparts but that’s not always the case. This is especially true with Medicare and certain types of inhalers, creams and eyedrops. In short, if you specifically want the brand name drug you or your doctor will have to confirm that with the pharmacist.
This isn’t the only reason why this may happen. There are some other rules that could affect what drug is given to you.
Step Therapy - Step therapy is a technique that is intended to help keep drug costs down through a “step up” process. What does that mean? Say a specialty drug (Ab) is prescribed to treat an illness. Ab is an expensive brand name drug that has same/similar generic versions available. With Step Therapy, before you can take drug Ab, you first have to try the similar/generic versions to see if those are effective. Until then you will not be able to fill Ab. Here is the definition from Wikipedia: “The practice begins medication for a medical condition with the most cost-effective drug therapy and progresses to other more costly or risky therapies only if necessary.”
This can be a frustrating requirement for people who have already tried the alternatives and had unsuccessful results. Fortunately there is a way around this but it can be a hassle in some cases. Usually your prescribing physician can speak with your insurance plan and attest that you already tried the other versions to no avail and the brand name/prescribed version is the most effective. This step may take multiple calls between your doctor, pharmacy and insurance plan. Usually, a doctors attestation will be sufficient enough to forgo the step therapy process and allow you to fill the script as intended.
Prior Authorization - Another reason you may be denied a medication or given a different one than prescribed is due to needing a prior authorization. This basically means your insurance company has to approve the medication before you’re able to fill the prescription. This is typically something you can find out beforehand but can come as a big surprise when going to pick up a regular prescription with new insurance.
To resolve a prior authorization issue it’s usually best to work with your doctor and contact your insurance plan. This is because the doctor can provide the medical reasons why the drug was prescribed. Similar to step therapy, prior authorization may require a generic alternative based on cost, medication interaction or other factors.
We’ve said it before and will certainly say it more moving forward but the drug market is a complex monolith. With so many moving pieces and day to day variables it can be hard for seasoned veterans to make sense of. However, we help individuals through complicated scenarios everyday in relation to their Medicare coverage. If you, a friend or a loved one are approaching Medicare and don’t know where to turn, we would be happy to help. Please feel free to leave a comment, email us at help@doctorschoiceusa.com or call us to set up a no cost consultation at 401-404-7373. As always, thanks for reading!