Darius Randeria      
Darius Randeria, RPh, BPharm, MRPS 
VP Staffing AHS PharmStat 
As Pharmacists, part of our daily job is to help patients manage the financial impact of their drug bill. Sometimes, our hands are tied but, on occasion, we can really make an impact. Physicians have a large arsenal of drugs at their disposal in most therapeutic classes and their choice of drug often leaves us wondering if they have considered the patient’s ability to pay for a certain medication. To be fair, I think that the writing of brand name prescriptions, especially the latest “Me too”, drugs has declined partly due to the pharmaceutical industry’s mandate to stop certain marketing practices and the shrinking of their sales forces. Also, insurance companies have become much stricter with Prior Authorizations and the physician offices have realized that these prescriptions will eventually end up costing them time and money when they have to change the therapy or call the insurance companies. Still, we often have to give patients other choices when they are presented with a bill that they cannot possibly pay. Medicare Part D plans are often the trickiest to deal with because in many instances, everything is fine until late in the year when one of their medications now costs hundreds of dollars. This was the case last week when an elderly lady came in to the pharmacy to pick up a prescription for Combivent and Spiriva. The price was over $400.00 and her only income was social security. She immediately became angry as I explained to her that she was likely in her “Donut hole”. She said that she had never had that happen before and that she had received no communication from her insurance company. I took time away from filling and called her insurance company. They told her the same unfortunate news. I then looked at her profile and discovered that she had been put on Vesicare, Nexium and Metaglip during the year. Without making this a case study, suffice it to say that these drugs could have been handled differently. The Vesicare could have been a second-line agent after Oxybutnin had been tried. The Nexium could have been bought over the counter and the Metaglip could have been split in to its generic components. I told her about upcoming enrollment and to check in to a Medicare Advantage plan or look at a MediGap policy. I spent time that day looking at the inhalers that we currently have, trying to find out what the lowest cost treatment might be for someone needing a long-acting bronchodilator and a steroid. The answer that I quickly came up with was that there was not one..not even close. If a patient needs to pay out of pocket for the treatment of asthma, COPD or emphysema, they are just “Out of Luck”. In 1989, Glaxo Wellcome and seven other (PDF) pharmaceutical firms formed the International Pharmaceutical Aerosol Consortium (IPAC) to come up with a new ozone-friendly product. By 1997, the first CFC-free inhalers hit pharmacy shelves. Further regulation banned the original CFC versions. The Pharmaceutical companies actually took a potentially bad situation for them and turned it around, patenting a host of new delivery systems, gaining years of brand protection and increasing prices by hundreds of percent. Any generic companies would not be able to compete because without the actual inhaler device, which was patented, they could not make their version. In actuality, inhaler technology has always been an interesting battle between building a reliable device and creating something that is easy to use even in the elderly population. It is one of the clearly important prescriptions to counsel thoroughly and we all know that improper synchronization leads to poor particle deposition in the smaller airways. As with all compliance issues, cost and the patient’s ability to actually buy the correct medication overrides all the billions of dollars of R&D invested in driving ease of use and compliance. Ironically, in these diseases, what ends up happening is that the patient stops buying the long-acting dilator or the steroid and over-uses the Albuterol rescue inhaler. This leads to an eventual rebound constriction, less than optimal opening of the airways and, of course, does nothing to treat the inflammation. The patient is also at risk of other Beta Adrenoceptor side effects. Often, they go back to the doctor and receive samples or, perhaps, we have a coupon that they can use but these are temporary fixes. Below, you can see some examples of price ranges amongst retailers. These are some representative strengths and there are some inhalers such as Dulera, Qvar, Combivent Respimat which are not included although their pricing is also comparable.
NAME TYPE DOSING DOSES/UNIT Monthly Annual
Advair (500/50) Steroid Long acting dilator BID 60 $220-$271 $2,640 - $3,252
           
Combivent Mixed short-acting QID 120 $210-270 $2,520 - $3,240  
           
           
Flovent HFA (220 Mcgs) Single Steroid BID 120 (2 mth Supply) $115-145 $1,380 - $1,740
             
Albuterol HFA type Different Brands) Fast Acting Rescue Variable Based on BID 200 $40-60 $480 - $720
           
           
           
           
The main point here is that any patient that is paying out of pocket or who has a deductible is going to have a hard time finding the money to stay on these therapies. A private pay patient could pay up to $5,000.00 per year just for two inhalers. Patients are turning to Canada to purchase these inhalers at a massive reduction. I understand that the system is not perfect but with a disease that is as common as asthma and COPD, It seems utterly ridiculous that patients really have no choice whatsoever than to dip in to their savings if they want to continue breathing.