My insurance co. just sent me a letter pertaining to my Rx plan and
th fact that Zetia has been moved up one class, to cost me more in the future.
They suggested that I switch to Lipitor, or other meds (all statins) that would be in the generic, or the less costly classification.
I switched from Lipitor to Zetia about 3 1/2 yrs ago to get away from statins because they exacerbate my PN symptoms, and give me back/shoulder and kidney area pains.
I've had to pay a higher price than the generics, for this need.
But now its going to be even more expensive.
Is there any info regarding why my ins co would do this? I'm not about to go back to statins. I'll pay the increased cost if necessary, but why would they be doing this?

--precisely because there have been more problems reported with the statin drugs recently, and there's been a bit of a movement to switch people to Zetia. With that increased demand, there may be somewhat of a pinch on supply--and when an insurance company sees a profit opportunity . . .

I wonder if you could get a letter from your doctor--or you could write yourself to your insurer--explaining why you CANNOT switch to one of the statins, given your neurological situation. (After all, many of the bad side effects of statins involve muscle and nerve pain.) You should also explain the fixedness of your income, status, etc. You may be able to argue that it's in their interest to let you continue Zetia at the previous rate rather than risk probable future complications (that they would have to pay for).

(Nah, that's too logical an argument for an insurance company to follow . But it doesn't hurt to try.)

I think this is an example of the aggressive style Pfizer uses to get what they want. Pfizer runs studies to show its statin is better than everything else.

They then lower they price a bit to encourage insurances to pay for brand name Lipitor instead of the generics. What you, Bob, don't know is that when drugs go generic (like Zocor, Pravachol, Mevacor now), the other drugs in that family, that are STILL brand like Lipitor, are bumped up to the next tier (like your Zetia). However, Lipitor used aggressive marketing tricks to keep it on tier one. Insurance companies want to pay as little as possible and so Pfizer knows how to sway them. It goes like this: "We lowered our price a bit, and show studies that reveal that your patients suffer less likely use of hospital and other medications, so using Lipitor tier one, is a cost saver". The study they are most likey using is the head to head, with Zocor..which was published just over a year ago.

Zetia is most likely up there in tier two, just because it is a "brand name".
Vytorin would be up there too.

Here is a bit of history for an example. Biaxin came out first (Abbott).this is a new form of erythromycin, improved to avoid severe GI upsets and improve bacterial killing effectiveness. Zithromax came out a little more than a year later (in the same family), and did not do well, since Biaxin was well accepted by doctors. So what happened? Pfizer reformulates the Zithromax into a "pak" so patients punch them out of a card. (once a day use was new in macrolide dosing as well).
Then they LOWERED the wholesale price of Zithromax to about 75% of what Biaxin cost. And bingo..Zithromax took over the whole market share, in no time! Pfizer knows how to get things done!

Putting Zetia in tier two, is not a denial of coverage. In a denial, you can
get prior authorization, to cover a noncovered item. It is slightly possible you could get prior auth for changing tiers, but I have only seen this a few times with antibiotics, and once with a blood pressure pill. (both were thru HMO's).
Since Zetia is still covered, you would have to check with your insurance company to see if any recourse in price is available to you.

It is a bummer, I know. Insurance companies are very powerful these days!

Yup! It is a bummer!
I'm sure that if I got my doc to state that I cannot take statins, my ins. co. would say :
"Fine, than pay up for what you can take- the brand name.
Sorry you have bad s/e but that's why we still cover it -
only it'll cost you more"
I think that I'll have just wasted a half day on the phone just trying to get to the right person to speak to (after being denied, and having to ask to speak to a supervisor's supervisor). I'm sure they make it that way, just to discourage people from getting what's rightfully thiers. What P.O.'s me is that my ins premium has jumped to over $100 more a month, from Dec '06 to Jan '07, and then I get this letter saying that even my Rx will cost more.
Its only $10.00 more per month for the script (from $20.00 to $30.00), but its the principle of the thing.
Ya know whaddamean, Vern?

Hi Bob:

I once remember having a conversation with one of my insurance reps on the phone about a prescription drug I was supposed to take. They had changed it from a name brand to a formulary (whatever the heck that meant). What it meant for ME, was it would be costing me $58 instead of $28 as a co-pay. I then told the rep on the phone, "I'm on disability, I need this drug, and I can't afford to pay the new price".

This is exactly what she told me. Now I have no idea if this can apply to you but it's worth a shot. She said:


"If your doctor writes a letter stating that you must be on this drug and that you can't take any other drug for your medical problem, then the insurance company HAS to give you the drug at the former price".

I just said to her "are you kidding me"? she said "No, this is done all the time but no one knows that they have to get their doctor involved and that their doctor has to write letters". "It goes to our medical management department and they review it and often (when they realize that YOU HAVE TO HAVE THIS PARTICULAR DRUG), they change the status of the drug down from the forumulary to the name brand and it's covered under the cheaper price"

Never knew this before.

Now this was a few years ago. I was in the process of changing my medicare advantage insurance plans so my new plan covered whatever the heck the drug was at the time (I'm 59 and don't remember anything anymore).

But you really have nothing to lose. To save a few bucks here and there and if you check with your insurance and they say to get a doctor's note, well, why not see if this is the way you can go.

I truly wish you luck in doing this. Sometimes it works, sometimes it doesn't.

Honestly, I find that sometimes it's WHO you get on the phone that matters, not the policy.

For example. I have a sattellite tv. I do not get Showtime or any premium channels because I can't afford them so if I want to see a clear tv picture I have to subscribe to basic cable.

There was something on Starz once and it would cost me $10 a month to subscribe to Starz. I simply called up the cable people and politely asked them if they could add on Starz so I could see the show I wanted. I explained my financial situation, I explained that my husband was on disability, did not drive any more we really don't get to go out very much, we don't go on vacations and all we really have is tv (and this is all true by the way), and there was this one show, so could she find it in her heart to do whatever they do to add on a premium channel and could she please do this for me.

This is exactly what happened when I asked her that. (Oh before I continue, let me explain what happens when they add a channel. They are in front of a computer system and all they have to do is press a button. Thats it. I know this because I watched a tv special on cable tv once. So I knew that the person I was speaking on the phone to at the time had it in her power to do exactly what I was asking her to do. BUT she didnt know that I knew this.

So after I politely asked her if she could give me the Starz fchannel for a few days she replies to me "Oh no, it's not in my power to do this, I can't do that, I'm so sorry". I then respond: "Oh, it's so kind of you to take to time to at least talk to me, my husband is disabled and I just wanted him to see his favorite movie, but I completely understand, and I thank you for your time".

Two seconds go by and she goes: "Welllllllllll, let me see what I can do".

Five minutes later, there was the Starz channel on my tv along with the other channels that come along with Starz, about 8 in all. All premium channels. I pretended to be in awe saying "oh my god, how did you do that, you are awesome and I appreciate what you did, my husband will be thrilled".

She said "I'm giving it to you for three months for free". I was flabbergasted.
I only thought I'd get it for a week or so.

THAT WAS REALLY SOMETHING. I learned then (as it applies to cable tv, I mean), it's how you ask for something and how you respond when you get it. My father taught me that years ago.

Oh by the way, I've been getting Starz, and showtime for FREE for over a year now. When the three months of one are up, I simply call and politely ask if they can extend it and that I would be very appreciative. Since it's only the push of a button, they are always gracious and now we can see showtime and Starz and (The Movie Channel too).

Now I have a friend who tried to do this. She called them up and asked and they said no we can't and she said thanks and hung up. I just shook my head.

So go and ask the insurance people if you get a note from your doctor detailing that you MUST be on this particular drug might this make a dent in their decision???

And if anybody reading this gets added cable stations, well, why not!!!!

Love, Melody

Thanks, Mel