Help! My Patient Doesn’t have Much Money:
Is there a Generic for that?
A look at OTCs and Generics
Amelie Hollier, DNP, FNP-BC, FAANP
President, APEA
Making the Most
of the $4 generics
1. Not all lists are the same
• And the lists change periodically
• Example: Benazepril/HCTZ available at
Walgreen’s but not Wal-mart
Making the Most
of the $4 generics
Keep $4 generic lists of local
pharmacies in your exam room
Making the Most
of the $4 generics
2. Not all generics are
on the $4 list!
• Example: amolodipine, fluticasone
nasal spray, losartan, many more!
Making the Most
of the $4 generics
3. Some doses of generics
are NOT on the list
• Example: Pravastatin 10, 20, 40 mg
Making the Most
of the $4 generics
• Pravastatin 80 mg (30 tabs)
• Price range: $18.99- $119.99
Making the Most
of the $4 generics
Can you take (two) 40 mg tabs
= (one) 80 mg tab? ($8)
• Pravastatin 80 mg (30 tabs)
• Price range: $18.99- $119.99 (without shipping)
4. Order 90 Day supply
instead of 30 Days
• Larger quantities (90 day supply
usually cheaper than 3-30 day
supplies)
Annualized savings:
• 1 script: $8 (12 months: $48 vs. $40)
• 5 scripts: $40
• 10 scripts: $80
5. Free Delivery is Free!!!
Gasoline!
6. Always consider $4 plan
$4 Plan may be cheaper
than with ins co-pay
Making the Most
of the $4 generics
7. Look for ways to
combine meds
• Example: HCTZ 12.5 mg daily
($4/30 tabs)
• Lisinopril 10 mg daily ($4/30 tabs)
Rx Case 1:
Patient takes lisinopril
10/HCTZ 12.5
• Lisinopril 10/HCTZ 12.5 mg tab
• Lisinopril 20/HCTZ 25 mg tab
Can you split a Lisinopril 20/HCTZ 25 mg
tab to get two doses?
Pill Splitting
Don’t split if tablet contains more
than ONE active ingredient
• Lisinopril/HCTZ
• Combo antihypertensive medications
Pill Splitting Clues
Don’t split if enteric coated,
sublingual, or buccal, some
extended release tablets
Pill Splitting Clues
Don’t split if medication is a narrow
therapeutic agent
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•
•
•
Warfarin
Levothyroxine
Anti-seizure medications
Others
Narrow Therapeutic Agents
Warfarin
Digoxin
Levothyroxine
Lithium
Phenytoin
Theophylline
(Toxic dose may be slightly above therapeutic dose)
Therapeutic Index
.5 mg
.3-.4 mg
0-.2 mg
TOXIC
Therapeutic range
No clinical effect
Pill Splitting
Price comparable despite tablet strength
Medication
Dose
Double Dose
Savings
Rosuvastatin
10 mg: $149
20 mg: $150
$74
Atorvastatin
20 mg: $154
40 mg: $160
$74
Pill Splitting
Some OTHER Considerations
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•
•
•
Sharp tablet cutter
Good dexterity
Cognitive ability
Visual acuity
8. Member Discount Plans
Many Businesses offer discounted
drugs if you are “a member”
• Membership: Free
• Membership: Fee
Member Discount Plans
Largest 8 Examples Nationwide:
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Costco: Free for members ($50/yr)
CVS: $15/year
Kmart Prescription Savings Club: $10/yr
Kroger: Free
Rite-Aid Rx Savings Plan: Free
Target: Free
Walgreen’s Prescription Savings Club: $20
individual/$35 family
• Wal-mart/Sam’s Club: Free
Combos are Cheaper, Right?
• More than 75% of hypertensive
patients need two or more meds
• Strategy: Use Combos???
Generics Save you Money,
Right?
Brand (Lotrel)
Generic
Amlodipine
$219.16
10/benazepril
40
Amlodipine
$32.75
10/benazepril
40
Savings with Generic: $186.41
Watch out! Don’t get taken!
At the same pharmacy…
Generic
Generic
Generic
Amlodipine
10/benazepril
40
Amlodipine 10
Benazepril 40
$32.75
$6.10
$5.90
$32.75 vs. $12.00
Across the street…
Amlodipine 10
$5.09
Benazepril 40
$4
Amelie’s Favorite Site!
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Free for iPhone, iPod Touch, and iPad
Online: www.goodrx.com
Finds lowest price drug in stores AND online
Taps into generic discount plans
Gives access to manuf coupons when there is
no generic
• Finds prices of generic “equivalents”
3 Other Sites
• Lowest Med
• Mobile Rx Card
• Pocket Doctor
Disease Specific Strategies to
Save Money
Do not underestimate
the $$$ value of
Education about
patient’s disease, the
medications
Asthma
If it comes in a canister….
Asthma
RESCUE MEDICATION!!!
• Albuterol: generic product, but the
propellants changed in 2008
• HFA more ozone friendly
• Cost is about $45-$48
Asthma
Mild persistent asthma:
Inhaled corticosteroids (ICS)
Moderate persistent asthma:
ICS plus LABA
Asthma
Moderate persistent asthma:
ICS plus LABA
Fluiticasone/salmeterol (Advair)
Budesonide/formoterol (Symbicort)
Mometasone/formoterol (Dulera)
Cost: $185 - $285/30day supply (BID dosing)
Price Comparison Inhaled
Combo Medications
•
•
•
•
Advair Diskus: $285.46
Advair HFA: $285.46
Dulera: $242.69
Symbicort: $259.08
Asthma
Moderate persistent asthma:
ICS plus LABA
Fluiticasone/salmeterol (GSK)
Budesonide/formoterol (AZ)
Mometasone/formoterol (Merck)
Cost: $185 - $285/30day supply (BID dosing)
Asthma
Fluiticasone/salmeterol (866-518-HELP or
www.gsk-access.com)
Budesonide/formoterol (800-292-6363 or
AZandMe.com)
Mometasone/formoterol (800-727-5400 or
www.merck.com/
merckhelps/patientassistance/)
Web-based Resources
www.needymeds.com
• Brand and generic meds available through
patient assistance programs
www.rxassist.org
• Patient can search medication by company,
brand or generic search; lists various options
for patient assistance
Web-based Resources
www.pparx.com
• Pharmaceutical Research and Manufacturers
of America (PhRMA). Search by
manufacturers; patient assistance programs
available
Anti-Histamines
Cost
1st gens cheaper/dose
2nd Gen Anti-Histamine
Cost per Dose
Cetirizine
.25/10 mg (generic)
Loratadine
.25/10 mg (generic)
Fexofenadine
$2/180 mg
Levocetirizine
$3/5 mg
Desloratadine
$4.06/5 mg
Hypertension
Lifestyle Modifications
• Maximize Non-pharm Management
• Institute lifestyle modifications
(change in diet, increase physical
activity, weight loss)
Hypertension
Life style Modifications
• DASH eating plan (8-14mm Hg)
• Weight loss (5-20 mm Hg/ 10kg)
• Exercise: 30 min most days
(4-9mm Hg)
• Sodium restriction (2-8 mm Hg)
• EtOH in moderation (<2
drinks/d): (2-4mm Hg)
• Eliminate other CV risk factors
Anti-Hypertensives
How do I pick one?
Multiple $4 Generics Available
• ACE inhibitors
• Alpha blockers and BB
• Thiazide diuretics
• CCBs
• Combos
Anti-Hypertensives
ARBs (not $4)
• Consider transitioning to
an ACE inhibitor
• Losartan, irbesartan,
valsartan, are generic (not $4)
• Candesartan generic 2012
Anti-Hypertensives
Generics
• Takes at least 6 months as a
generic before price begins
to decrease
• Occurs as multiple
manufacturers produce
drugs
Anti-Hypertensives
Alpha Blockers
• Doxazosin (Cardura): once daily
• Prazosin (Minipress): 2-3 times daily
• Terazosin (Hytrin): once or twice daily
Anti-Hypertensives
Beta Blockers
• Metoprolol tartrate (twice daily): $4 med
• Metoprolol succinate (once daily)
• Not for uncomplicated HTN
Anti-Hypertensives
Alpha/Beta Blocker
• Selective alpha, non-selective beta
• Carvedilol (Coreg): twice daily
• Dose: 3.125 mg – 25 mg BID
Anti-Hypertensives
Think Combos
• Most patients need more than one drug
anyway
• ACE/HCTZ
• Atenolol/chlorthalidone
• Carvedilol
• K+ sparing/HCTZ
Anti-Hypertensives
What about Samples?
Free is better than cheap!!!! but…..
Hyperlipidemia
Lifestyle Modifications
• Maximize Non-pharm Management
• Institute lifestyle modifications
(change in diet, increase physical
activity, weight loss)
Lipid Lowering Meds
$4 generics
Lovastatin
Pravastatin
Statin Efficacy
$4 Generic Medications
Atorvastatin
Simvastatin
Lovastatin
Pitavastatin
Pravastatin
Rosuvastatin
LDL
Decrease
38-54%
28-48%
29-48%
31-41%
19-40%
52-63%
Dose
10-80mg
10-80 mg
20-80 mg
1-4 mg
10-40 mg
10-40 mg
$15-16
$17.99 - $35.99
Generic sometimes $4
Atorvastatin
Pill Splitting
Price comparable despite tablet strength
Medication
Dose
Double Dose
Savings
Rosuvastatin
10 mg: $149
20 mg: $150
$74
Atorvastatin
20 mg: $154
40 mg: $160
$74
Simvastatin
Mail Order Medications
Statin Considerations
Drug Interactions
CYP 450 Effect
LDL
Decrease
CYP 450
Effect
Atorvastatin
Simvastatin
Lovastatin
Pitavastatin
Pravastatin
Rosuvastatin
38-54%
10-80mg
28-48%
10-80 mg
29-48%
20-80 mg
31-41%
1-4 mg
19-40%
10-40 mg
52-63%
10-40 mg
No
significant
No
No significant
interactions
significant
interactions
interactions
3A4
3A4, 3A5
3A4
Diabetes
Oral Agents
• Metformin
• ER and BID formulations
• Maximize doses
Diabetes
Sulfonylureas
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•
•
•
Glimepiride
Glipizide
Chlorpropamide
Glyburide
Diabetes
Discourage use
Chlorpropamide, Glyburide
• Increased weight gain
• Prolonged hypoglycemia
Basal Insulin
• Sound familiar? Like the Inhaled combo
meds for asthma: there are no generics
of basal insulin
• Insulin glargine (Lantus)
• Insulin detemir (Levemir)
Basal Insulin
• Vials are cheaper than pens
• Pens are more convenient
• Look for programs (basal insulins have
patient programs)
Basal Insulin
Basal Insulin
Web-based Resources
Insulin Acquisition
www.pparx.com
• Pharmaceutical Research and Manufacturers
of America (PhRMA). Search by
manufacturers; patient assistance programs
available
Depression
2010 American Psychiatric
Association guidelines for major
depressive disorder
American Psychiatric Association. Practice guideline for the treatment of patients with major
depressive disorder (3rd Edition). October 2010. http://www.psych.org/guidelines/mdd2010.
(Accessed February 18, 2011).
Depression
• Most meds are similarly effective!
• None more effective than another
• Choose one based on side effects (or lack of
them!)
American Psychiatric Association. Practice guideline for the treatment of patients with major
depressive disorder (3rd Edition). October 2010. http://www.psych.org/guidelines/mdd2010.
(Accessed February 18, 2011).
Depression
SSRIs
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•
•
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Citalopram
Fluoxetine
Paroxetine
Sertraline
Depression
Depression with insomnia
•
•
•
•
Consider paroxetine ($4 generic med)
Consider a sedating TCA ($4 generic med)
Mirtazapine (Remeron) generic; some $4 lists
Both associated with weight gain
Depression
Depression with fatigue, sleepiness
• Consider bupropion SR (BID, not on all $4
lists)
• Consider a less sedating SSRI: fluoxetine
• Generic but not $4: Bupropion XR,
Venlafaxine
***Less weight gain, fewer sexual side effects
*** Hypertension with bupropion, venlafaxine
Depression
Depression with chronic pain, migraine
prophylaxis
• Amitriptyline (10, 25, 50, 75, 100 mg
tabs)
• Nortriptyline (10, 25 mg tabs)
***Migraine prophylaxis
Depression
SSRIs (if no response, try a different one)
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•
•
•
Citalopram
Fluoxetine
Paroxetine
Sertraline
McGrath PJ, Stewart JW, Fava M, et al. Tranylcypromine versus venlafaxine plus mirtazapine
following three failed antidepressant medications trials for depression: a STAR*D report. Am J
Psychiatry 2006;163:1531-41.
Exercise
Proton Pump Inhibitors
7 Different ones on the Market
•No clinically significant difference for
esophagitis healing, symptom relief,
prevention of GERD relapse
•None clinically significant for treating ulcers,
NSAID induced ulcers, duodenal ulcers or H.
pylori
•No difference in side effects
Gastroenterology, 2008; 135:1392-1413
Proton Pump Inhibitors
6 Different ones on the Market
Generic
PPI Brand Name
Dexlansoprazole
Dexilant (Kapidex)
Lansoprazole
Prevacid, Prevacid OTC
Omeprazole
Prilosec, Prilosec OTC
Esomeprazole
Nexium
Omeprazole + Na bicarb
Zegerid, Zegerid OTC
Pantaprazole
Protonix
Rabeprazole
Aciphex
Proton Pump Inhibitors
Drug Interactions
PPI
Dexlansoprazole
How Metabolized
2C19, 3A4
Lansoprazole
2C19, 3A4, induces 1A2, inhibits
2C19
Omeprazole
2C19, 2C9, 3A4; inhibits 2C19, 2C9;
induces or inhibits 1A2
Esomeprazole
Omeprazole + Na bicarb
2C19, 3A4,
inhibits 2C19
2C19, 2C9, 3A4; inhibits 2C19, 2C9,
induces or inhibits 1A2
Pantaprazole
2C19, 3A4; inhibits 2C19
Rabeprazole
2C19, 3A4; inhibits 2C19
H2 Blockers
All inexpensive
All OTC
All generic
Onset of action 1-2 hours
Duration: 6-12 hours for most
H2 Blockers
H2 Blocker
Generic
How Metabolized
Tagamet
Cimetidine
Pepcid
Famotidine
Axid
Nizatadine
Multiple enzymes
inhibited and used
for metabolism
(3A4)
Min CYP 450
involvement
Min CYP 450
involvement
Zantac
Ranitidine
Min CYP 450
involvement
Free Antibiotics
•
•
•
•
•
•
•
•
Amoxicillin
Ampicillin
Cephalexin
Ciprofloxacin
Doxycycline, Tetracycline
Erythromycin
Pen VK
SMZ/TMP DS
GoodRx.Com
Did not pull up the FREE antibiotics in my area
Wrap Up!
Don’t overlook the Obvious!
Watch out! Don’t get taken!
At the same pharmacy…
Generic
Generic
Generic
Amlodipine
10/benazepril
40
Amlodipine 10
Benazepril 40
$32.75
$6.10
$5.90
$32.75 vs. $12.00
Across the street…
Amlodipine 10
$5.09
Benazepril 40
$4
Utilize ALL of your
Resources
Thank you!
For questions or to contact me:
Amelie Hollier
amelie@apea.com
Advanced Practice Education Associates
Lafayette, LA