BLOG: When medication coverage is meaningless
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Lunchtime reading: the point/counterpoint discussion of ocular surface issues in glaucoma care between Drs. Laura Periman and Doug Rhee. (I’m a little behind on some of my reading.)
Context: lunch immediately following a patient who had cataract surgery at a large academic center that only allows prescription of generic medications, and another who was told their Medicare Part D “covered” Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) prescription would cost $480 for a single month. For the record, I am first-name friendly with both Drs. Periman and Rhee.
A quick review of the discussion shows Laura laying out the enormous burden the ocular surface carries when a patient with glaucoma is treated topically with either branded or generic eye drops. Keratitis, meibomian gland dysfunction and allergy on the surface of the eye, and adherence challenges with complex regimens, often requiring an immunomodulator to save the surface. Doug countered with the observation that there are branded medications with newer, less toxic preservatives than benzalkonium chloride, several preservative-free options and procedural options such as selective laser trabeculoplasty and the Durysta injectable from Allergan. He concluded by heralding a “new era” for the management of glaucoma.
How are my two late-morning patients, neither one of whom has glaucoma, related to the article?
On first blush, it’s impossible not to agree with Doug. Indeed, my column in this same issue highlights all of his points. The problem, of course, is that a supermajority of patients effectively have no insurance coverage for any of the medications that are mentioned. Neither the alternatively preserved nor the non-preserved. Even for a patient who has a clear drug intolerance with severe side effects, the out-of-pocket cost of the branded alternative is off the charts. How else can we explain the across-the-board policy of our local version of Man’s Best Hospital (see: The House of God): They don’t even bother. That cataract patient I saw paid big bucks for a premium IOL and still got generic Maxitrol for their postop drop. Now I take care of the dry eye and ocular surface inflammation caused by her generic med.
There is one single overriding and near universal truth: the existence of an option that is unavailable for whatever reason is precisely equivalent to a world in which that option does not exist. Corollary No. 1: making a better product that is inaccessible is precisely equivalent to making a lousy product. Corollary No. 2: if affordability requires so much time and effort that very large, very famous institutions don’t even try to write the prescription, it is precisely equivalent to not making that product.
There’s much more to come on this topic.
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