I hate coupons that reduce the copay of prescription meds.  I just refuse to use them.  Today essentially all insurance companies divide their medications into tiers, where the lowest tier is for inexpensive generic meds., the next tier is for more expensive generics and branded drugs that the plan negotiates substantial discounts from the manufacturer in exchange for encouraging their use on the plan, and the third tier is for more expensive drugs and the rest of the branded drugs that did not win in the negotiations to be tier 2 on the plan.  The purpose of these is to provide incentive to physicians and patients to try to manage patients health using the least expensive medications possible.  These coupons are designed to take away this incentive to use less expensive drugs.  Drug salespersons tell us that their expensive drug is just as inexpensive to the patient as lower tier or generic meds, because they will pay the pharmacist for most of the copay.  Obviously in all these cases the profit margin for the company is so high they can discount the Rx by a large amount and still afford to pay a sales person, print the coupons, manage the bookkeeping, and come out ahead.  I find this subversion of the system just wrong, and don’t participate.  Government plans, Medicare and Medicaid do not allow pharmacists to accept coupons for meds for patients they insure.  This was never more in my face than today at the office.

I was again appalled today at the audacity of the pharmaceutical industry and their pricing.  A drug rep told me about a great new sleeping medication that is not a benzodiazepine, has a low side effect profile, is a non-schedule drug, and is ideal for the typical patient we struggle with, i.e. has trouble falling asleep and staying asleep for more than a few hours.  She then told me that this is a new dosing regimen of an old drug doxepin.  I grew up in medicine with the tricyclic antidepressant meds.  Doxepin was sold as Sinequan, a branded drug when I was a med student, has long been used as a very sedating antidepressant.  It has been used more recently for help with chronic pain, as an add-on med in depression when sleep is needed, and sometimes alone for insomnia.  It is available as a generic in doses of 10,25,50,100 and 150 mg all except the 150 mg doses for $4./ 30 doses at the discount pharmacies.  The drug rep assured me that I did not need to worry about the cost of this medication, because although the med will the in the highest tier copay on essentially all plans, i.e. $ 40-$60./ month for most patients, they would supply coupons to reduce this copay by $25./ month so the “real” cost to the patient will be only $15-35.  As always, I asked her what the real cost is, and after some arm twisting she told me it was about the same as the other “branded” hypnotics.  Asked how much this is she said about $200./ 30 pills.  The new drug is called Silenor, and is simply doxepin packaged in a smaller dose, of 3 and 6 mg.  I presume that this company buys generic doxepin in bulk, that is available as a generic  100 mg dose for  $0.13/ dose and sells 3/50^th   or 3/25^th  the dose for 51x as much as the higher dose.  I was told that they need this pricing to pay for all the research they needed to do to allow them to bring this lower dose to market.  The rep did not mention they also needed to  hire a sales force good enough to somehow convince feeble minded physicians that this somehow is better than a dose of ½ of a 10 mg of the generic. 

Usually I don’t waste my breath, but this was so insane that I gave the rep my usually silent rant about how unethical coupons are, as they essentially remove the disincentive for patients to try to hold down medication costs that the high tier copays are designed to provide.  I added a tirade about their need to pay for the research was not really necessary, because the research only served to allow them to “brand” this low dose of an available generic medication, and to send reps to the field to sell this drug.  She was obviously used to these responses, because when I told her she had a tough sell in front of her, she simply moved on to the next doc and started her sales pitch again.   If any of you are unfortunate enough to have a physician who is convinced that somehow this new dose of doxepin is what you need, just go ahead and ask them to try generic doxepin, save yourself a little money, and take a tiny step toward controlling health care costs.