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    Coping with patients who come bearing coupons


     It’s hard for organizations besides manufacturers to recognize coupons as they are being processed at pharmacies because the coupons are usually processed as secondary insurance claims, after the patient’s primary insurance claim has been processed. This approach keeps insurers from blocking coupon use. The reason that it can be impossible to distinguish a coupon claim from a secondary insurance claim is that both manufacturers and insurers use banking identification numbers (BINs) to direct claims through a pharmacy’s claims transaction system. Manufacturers do not reveal the BINs that are tied to coupons to outside organizations, such as insurers.


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    Say a certain patient usually has a 20% copayment for prescribed medications. That patient might buy a generic drug that costs $600 and is just as effective as a brand name drug costing $1,000, for which the patient has a coupon covering the full copayment.  For the generic drug the patient copayment would be $120, at 20%, and the insurer would pay the remaining 80%, or $380. By using the coupon, the patient avoids what would have been a $200 copayment (20% of $1,000), and the drug maker pays that $200 to the pharmacy. Meanwhile, the insurer is left to pay $800, or 80% of the cost of the $1,000 branded drug. That $800 copay is $420 higher than the amount that the insurer would have paid with the generic drug. Multiply that $420 in extra spending by, say, 5,000 transactions, and you get a total of $2.1 million in additional spending on the part of the insurer, who passes the costs on to patients as higher premiums.

    Discussing real value with patients

    Martin Derrow, MD, who practices internal medicine in Maitland, Florida, says that he usually writes prescriptions for generic drugs, which generally work well for patients with the chronic diseases that he often treats: diabetes, high blood pressure and coronary disease. Coupons just are not valuable in those cases, he says.

    Pharmaceutical manufacturers generally issue coupons for costly, newer drugs. Derrow says that he usually explains to a patient who arrives with a coupon that the generic may be a better choice overall.


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    “I tell them that I use medicines that have solid evidence to support their use,” he says. He explains that the use of generics is often supported by long-term outcomes data. Such data shows real improvements in measures such as mortality or, in the case of diabetes, the likelihood of having nerve damage or kidney failure. In contrast, for newer drugs, such outcomes data is often unavailable. The data that is available for expensive, new drugs may reflect markers only—something like an A1C level, rather than kidney failure or blindness, in the case of a diabetes drug. 

    Derrow will, at times, prescribe a branded drug, for which a patient has a coupon. He said that he does so when the drugs he normally prescribes are not working well, and he needs an alternative.

    Mark Puffenberger, MD, a partner with the InterMountain Medical Group in Kingston, Pennsylvania, reports that few of his patients ask to use coupons. When it has happened, he says, he has generally written the prescription for the drug the patient requested.

    “Honestly, if they want it and can get it for zero copay, I would prescribe it even if the generic is available,” he says. “It may be the wrong answer for the healthcare system as a whole, but when it’s just me and the person in the room, I am going to do what’s best for them.”

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