The Ambien Prior Authorization

Dear new RPh's and techs,

A post for my retail pharmacy people and those insomniacs whose insurance refuses to pay for sleep pills.

Just about the middle of last year, I started to notice that refills for zolpidem, generic Ambien, was being rejected for a prior authorization. This means that the insurance company wants to talk to the doctor to make sure that the patient really, really needs the medicine. What it really means is that insurance companies are the spawn of the devil and don't want to pay for anything.

A quick note about insurance companies: their business model is to take regular premiums from their customers and find ways to NOT pay out claims. One of the sneaky ways they do this is to send out brand new cards every year so that they can expire the old ones and hopefully not pay for a refill. In doing so, they make my job sucky for a few months out of the year, even more than usual with having to deal with insurance.

Most of the time though, their prior authorizations (PA) are well founded: rejecting an ADHD med for a kid who is 4 years old (my goodness, are we going to pump 1 year-olds with Ritalin next because they cry too much? wait a minute, we do! *sad face*), rejecting Cambia(R) because it's glorified ground-up diclofenac*, and rejecting Nexium(R) because it's basically rehashed omeprazole whose patent had run out**.

To these situations, I must say to the insurance co's, 'Nicely done. If I had more time to talk to the doctors to convince them to use medicines judiciously, I'd do the same. But since I'm here to dispense drugs pursuant to a prescription, I'd really wish that you'd make my life easier and just approve the medicine for a $200 copay so I can tell the patient to take it or leave it or take it up with their insurance/doctor. Because a PA makes it look like the pharmacy is being withholding, when it is in fact, you who are the angry wife (who is withholding of the marital obligation). Thank you.'

But I just don't understand when they reject meds which are comparatively dirt cheap (in the $40 range). Branded Lamisil tablets used to be prohibitively expensive, but the generic isn't too bad. Come on, guys! Let the old dude have it for his onychomycosis! Or when they rejected generic zolpidem when they had paid for it the first couple of months.

But then I remembered the lecture I gave on sleep disorders shortly after I graduated***: Ambien is FDA-approved for 'short-term treatment of insomnia characterized by difficulties with sleep initiation. Ambien has been shown to decrease sleep latency for up to 35 days in controlled clinical studies.'

Bingo! The resident medical 'expert' at the insurance department picked up on the little bit of important information (the package insert that accompanies the drug bottle), and found a great reason to reject refills of Ambien. 'Dear Dr. so-and-so: As you can see from the package insert, Ambien (Zolpidem) is not approved for treatment lasting longer than 35 days. Thank you.'

Anyone with any bit of reason (even insurance companies) knows that Ambien doesn't simply stop working after 35 days because the drug isn't approved for long-term treatment. It simply meant that Sanofi-Aventis didn't have the money to run the trial longer or were afraid that the sleep-inducing effects would wear off after 35 days and would lead to not-so-good-looking clinical results. As such, the drug is FDA-labeled for short-term treatment and now insurance companies have a perfectly valid reason to reject a claim using a prior authorization.

They could run longer trials now, but they won't because Ambien is generic, so they couldn't re-coop their expenses.
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So why know all of this? Because it is always better to explain to customers how it really isn't your fault. When you pass the buck to other folks, preferably drug or insurance companies, customers can get angry at them instead of at you. By the way, don't pass the blame to their doctor, because they may really like their doctor or their doctor may call and chew you out.

'Why is my insurance not paying for my medicine?'

*Smile* 'Well, sir. Ambien is not approved for long-term treatment of insomnia. Though I realize that you've been using it for years now, the original studies approving the medicine was only for short-term treatment. I think the insurance company wants to run this by with your doctor and make sure that there isn't a better way to treat your insomnia.'

Congratulations! The customer is no longer angry at you, and thinks you're pretty swell for your insurance knowledge. He shakes your hand, happily pays the ~$40 for the cash price of Ambien, and will take it up himself with his doctor/insurance.

Based on a true story.

Incidentally, you could also recommend the customer to get a prescription for Temazepam (generic Restoril) which is only about $20 per month without insurance.
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*I wanted to tell the patient to get a prescription for diclofenac 50 mg, buy a mortar and pestle, grind the pills up herself to put in water, and save $200 for 5 friggin packets!

**Please explain this to me: Omeprazole 20 mg and Nexium 40 mg are the most commonly dispensed strengths. We are made to believe that the S-enantiomer is supposedly the more active (or only active) component of the racemic mixture, and/or that it has less side effects. Therefore, if Omeprazole 20 mg contains 10 mg of the S-enantiomer (Nexium) and 10 mg of the R-enantiomer, wouldn't the equivalent strength of Omeprazole 20 mg be Nexium 10 mg?

So why does AstraZeneca market Nexium 40 mg which would be in essence, a four-fold increase in strength vs Omeprazole 20 mg (Prilosec, which they made)? Don't give me some BS about how there are fewer side effects so you could give a higher dose--show me a person who was taken off omeprazole for side effects and I'll show you a hypochondriac.

***Excuse the not-so-subtle reference to my genius :)