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, FAANPPresident, APEA

Making the Most

1. Not all lists are the same• And the lists change periodically• Example: Benazepril/HCTZ available at

Walgreen’s but not Wal-mart

of the $4 generics

Making the Most

Keep $4 generic lists of local pharmacies in your exam room

of the $4 generics

Making the Most

2. Not all generics are on the $4 list!

• Example: amolodipine, fluticasone nasal spray, losartan, many more!

of the $4 generics

Making the Most

3. Some doses of generics are NOT on the list

• Example: Pravastatin 10, 20, 40 mg

of the $4 generics

Making the Most

• Pravastatin 80 mg (30 tabs)• Price range: $18.99- $119.99

of the $4 generics

Making the Most

• Pravastatin 80 mg (30 tabs)• Price range: $18.99- $119.99 (without shipping)

of the $4 generics

Can you take (two) 40 mg tabs = (one) 80 mg tab? ($8)

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!

$4 Plan may be cheaper than with ins co-pay

6. Always consider $4 plan

Making the Most

7. Look for ways to combine meds

• Example: HCTZ 12.5 mg daily ($4/30 tabs)

• Lisinopril 10 mg daily ($4/30 tabs)

of the $4 generics

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 SplittingDon’t split if tablet contains more

than ONE active ingredient• Lisinopril/HCTZ• Combo antihypertensive medications

Pill Splitting CluesDon’t split if enteric coated,

sublingual, or buccal, some extended release tablets

Pill Splitting CluesDon’t split if medication is a narrow

therapeutic agent• Warfarin• Levothyroxine• Anti-seizure medications• Others

Warfarin

Digoxin

PhenytoinTheophylline

Levothyroxine

Lithium

(Toxic dose may be slightly above therapeutic dose)

Narrow Therapeutic Agents

TOXIC

Therapeutic range

No clinical effect0-.2 mg

.3-.4 mg

.5 mg

Therapeutic Index

Pill SplittingPrice comparable despite tablet strength

Medication Dose Double Dose Savings

Rosuvastatin 10 mg: $149 20 mg: $150 $74Atorvastatin 20 mg: $154 40 mg: $160 $74

Pill SplittingSome OTHER Considerations• Sharp tablet cutter• Good dexterity• Cognitive ability• Visual acuity

8. Member Discount PlansMany Businesses offer discounted

drugs if you are “a member”

• Membership: Free• Membership: Fee

Member Discount PlansLargest 8 Examples Nationwide:• 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???

Brand (Lotrel) Amlodipine 10/benazepril

40

$219.16

Generic Amlodipine 10/benazepril

40

$32.75

Savings with Generic: $186.41

Generics Save you Money, Right?

Watch out! Don’t get taken! At the same pharmacy…

Generic Amlodipine 10/benazepril

40

$32.75

Generic Amlodipine 10 $6.10Generic Benazepril 40 $5.90

Amlodipine 10 $5.09Benazepril 40 $4

Across the street…

$32.75 vs. $12.00

Amelie’s Favorite Site!• 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

AsthmaIf it comes in a canister….

AsthmaRESCUE MEDICATION!!!• Albuterol: generic product, but the

propellants changed in 2008• HFA more ozone friendly • Cost is about $45-$48

AsthmaMild persistent asthma:

Inhaled corticosteroids (ICS)

Moderate persistent asthma:

ICS plus LABA

AsthmaModerate persistent asthma:

ICS plus LABAFluiticasone/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

AsthmaModerate persistent asthma:

ICS plus LABAFluiticasone/salmeterol (GSK) Budesonide/formoterol (AZ)Mometasone/formoterol (Merck)

Cost: $185 - $285/30day supply (BID dosing)

AsthmaFluiticasone/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 Resourceswww.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 Resourceswww.pparx.com• Pharmaceutical Research and Manufacturers

of America (PhRMA). Search by manufacturers; patient assistance programs available

Anti-Histamines

Cost1st 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-HypertensivesHow 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

LovastatinPravastatin

Statin Efficacy

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

$4 Generic Medications

Generic sometimes $4

$17.99 - $35.99$15-16

Atorvastatin

Pill SplittingPrice comparable despite tablet strength

Medication Dose Double Dose Savings

Rosuvastatin 10 mg: $149 20 mg: $150 $74Atorvastatin 20 mg: $154 40 mg: $160 $74

Simvastatin

Mail Order Medications

Statin Considerations

Drug Interactions

CYP 450 EffectAtorvastatin Simvastatin Lovastatin Pitavastatin Pravastatin Rosuvastatin

LDL Decrease

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

CYP 450 Effect

3A4 3A4, 3A5 3A4 No significant interactions

No significant interactions

No significant interactions

DiabetesOral Agents• Metformin• ER and BID formulations• Maximize doses

DiabetesSulfonylureas• Glimepiride• Glipizide• Chlorpropamide• Glyburide

DiabetesDiscourage useChlorpropamide, 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

www.pparx.com• Pharmaceutical Research and Manufacturers

of America (PhRMA). Search by manufacturers; patient assistance programs available

Insulin Acquisition

Depression2010 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).

DepressionSSRIs • Citalopram• Fluoxetine• Paroxetine• Sertraline

DepressionDepression 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

DepressionDepression 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

DepressionDepression with chronic pain, migraine

prophylaxis• Amitriptyline (10, 25, 50, 75, 100 mg

tabs)• Nortriptyline (10, 25 mg tabs)

***Migraine prophylaxis

DepressionSSRIs (if no response, try a different one)

• 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 Inhibitors6 Different ones on the Market

Generic PPI Brand NameDexlansoprazole Dexilant (Kapidex)

Lansoprazole Prevacid, Prevacid OTC

Omeprazole Prilosec, Prilosec OTC

Esomeprazole Nexium

Omeprazole + Na bicarb Zegerid, Zegerid OTC

Pantaprazole Protonix

Rabeprazole Aciphex

Proton Pump InhibitorsDrug Interactions

PPI How MetabolizedDexlansoprazole 2C19, 3A4

Lansoprazole 2C19, 3A4, induces 1A2, inhibits 2C19

Omeprazole 2C19, 2C9, 3A4; inhibits 2C19, 2C9; induces or inhibits 1A2

Esomeprazole 2C19, 3A4, inhibits 2C19

Omeprazole + Na bicarb 2C19, 2C9, 3A4; inhibits 2C19, 2C9, induces or inhibits 1A2

Pantaprazole 2C19, 3A4; inhibits 2C19

Rabeprazole 2C19, 3A4; inhibits 2C19

H2 Blockers

All inexpensiveAll OTCAll genericOnset of action 1-2 hoursDuration: 6-12 hours for most

H2 BlockersH2 Blocker Generic How Metabolized

Tagamet Cimetidine Multiple enzymes inhibited and used

for metabolism (3A4)

Pepcid Famotidine Min CYP 450 involvement

Axid Nizatadine 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.ComDid 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 Amlodipine 10/benazepril

40

$32.75

Generic Amlodipine 10 $6.10Generic Benazepril 40 $5.90

Amlodipine 10 $5.09Benazepril 40 $4

Across the street…

$32.75 vs. $12.00

Utilize ALL of your Resources

Thank you!For questions or to contact me:

Amelie Hollieramelie@apea.com

Advanced Practice Education Associates

Lafayette, LA