Prescription drugs are not equivalent to nutritional supplements

Recently I have prescribed medication which was not covered by insurance because it was supposedly available as a dietary supplement.

The first case was a 52-year-old man with severe hypertriglyceridemia on fenofibrate and niacin ER. He had been hospitalized with pancreatitis twice. His triglycerides remained in the thousands. I prescribed esterified omega-3 (Lovaza, GlaxoSmithKline) 4,000 mg per day but my prescription was not approved. The pharmacist advised him to take dietary supplement fish oil two caps per day instead. Although the label said “Fish Oil 1,000 mg,” the actual EPA/DHA content per capsule was only 300 mg. In order to get a therapeutic dose of 4,000 mg omega-3, he needed to take a total of 12 capsules per day — not two.

We attempted to get his insurance provider to consider covering prescription esterified omega-3, but they declined. “Our plan does not cover nutritional supplements,” they replied. The patient did not tolerate the required high number of dietary supplement caps because of fishy eructation; his triglycerides have not budged.

I wonder what the cost will be if he is hospitalized again for pancreatitis?

The next case was a 43-year-old woman with hypertriglyceridemia, low HDL and elevated lipoprotein (a). She was already on statin and fibrate. I prescribed niacin ER (Niaspan, Abbott Laboratories) but this was rejected because it is a “vitamin.”

I submitted a letter explaining that there is no over-the-counter equivalent to prescription niacin ER. Nutritional supplement immediate-release niacin requires multiple doses per day and is limited by severe flushing, resulting in most patients stopping therapy. Over-the-counter sustained-release niacin (slow niacin) has a very high rate of hepatotoxicity, up to 50%. This is not the same as the mild elevation of transaminases that we occasionally see with statins, usually of no concern. A few have experienced fulminant hepatic necrosis. The risk with niacin ER is much less due to a different metabolic pathway. Niacin ER is also better tolerated than niacin IR with less flushing.

We received a response; our letter will be discussed at their next formulary committee meeting.

The final case was a 32-year-old man with hypoparathyroidism. He did well on oral calcium and calcitriol until he got a new job and new health insurance. His new provider refused to pay for calcitriol because it is a vitamin. Letters explaining the difference between calcitriol and cholecalciferol/ergocalciferol fell on deaf ears. They declined to cover even after he had to be treated in the emergency room for hypocalcemia. After his fourth hospital visit for tetany and seizure they finally agreed to cover.

I wonder how many months of prescription could have been paid for if we had avoided even one of those emergency room visits?

Even though some products may technically be “vitamins,” this does not mean that they are the same as non-prescription nutritional supplements. Insurance companies must balance the costs of prescription medication with the potential risks of not covering.