Case Study: Addressing Tough Rx Questions

  • Originally published October 3, 2017 , last updated April 27, 2021
  • MA-PD, Medicare Advantage, AEP
Case Study: Addressing Tough Rx Questions

Your clients’ prescription drugs are a critical component to their health. Finding clients the right plan and coverage for their medication is a crucial part of an agent’s role. Clients are sometimes faced with questions and cost challenges that go beyond just considering a generic instead of a brand name. SMS has an in-house pharmacist that can help you look at challenging cases. Here is one such case.  

The Problem

A client was taking Metformin HCL 1000mg Immediate Release (IR), which costs less than $10 per month retail. They had an unpleasant side effect from the IR form, so their doctor prescribed the same medication in the Extended Release (ER) form (Metformin HCL 1000mg ER) to minimize the side effect.

An updated look at the client’s medication list on reveals that Metformin HCL ER 1000mg is NOT covered in their Part D formulary, and the retail cost for it is thousands of dollars per month.

The client is faced with a massive price increase or having to endure the side effect from the IR version of Metformin in a 1000mg dose.

The Solution

“There exist several different brand and generic options for Metformin ER. Some of them are very expensive. But in my opinion, there is no added advantage to the more expensive forms,” said Ryan Vlasin, Manager of Marketing & Sales Support, Pharmacy Director at Senior Market Sales.

The generic for Glucophage XR (also Metformin ER) is less than $25 for a month supply without insurance. On the other hand, the generic for Fortamet is nearly $1,000 per month and is essentially the same as the $25 version. The obvious solution would be to switch to the cheaper XR version for $25.

The price of Metformin ER 1000mg has varied dramatically the last two years and many carriers have dropped it from the formulary. But the price of the 500mg ER strength has been steady, and is often covered as a tier 1 on several plans. The client can ask their doctor or pharmacist to change the script to Metformin ER 500mg and then take two tablets daily or one tablet twice daily to get the 1000mg dose they need.

In addition to the issue of some plans only covering the 500mg ER and not the 1000mg ER, there are actually three different Metformin ER 500mg dosage forms with different release mechanisms.

It’s important to make sure that the generic being selected is the same dosage form and has the same drug release mechanism. This can also lead to some confusion.

Looking at Metformin ER tablets in this case, some state “modified release” in the description. Those “modified release” tablets are generic versions of a similar — but more expensive — brand name product (Fortamet). You do not want to select that by mistake if the client is taking the regular Metformin ER 500mg that is a generic for Glucophage ER. 

Clients should always consult with their doctor and pharmacist about any potential changes to their medication.

Next Steps

Having the ability to reach out to a pharmacist is important in difficult cases, so you can be assured that you are giving their clients the most accurate information for quoting.

Ryan Vlasin puts his Doctor of Pharmacy degree and bachelor's degree in biochemistry and molecular biology to work for agents. In addition to working as chemist for Pfizer and nearly a decade of pharmacy experience, Ryan is licensed and certified to sell all Medicare products. He understands the challenges agents face regularly.

Contact your SMS marketing consultant to gain access to Ryan's time and expertise when you're facing a difficult situation with a client's prescription drug plan.