Free prescription drug samples cost patients more money

in Meds | 29 responses

by Leslie Ramirez, MD

Free is good, right? If you have to pay out of pocket for medicines, free prescription drug samples from your doctor’s office might seem like a godsend. But nine times out of ten, these free samples end up costing you more money. Here’s how.

First of all, pharmaceutical reps only get paid to give out brand new medicines that their companies are trying to promote. They are giving out these drugs (or vouchers for a free prescription) in the hopes of getting the doctors more familiar with using and prescribing the new medicine and to encourage docs to start their patients on them.

Many docs, myself included once upon a time, really want to help their patients out by giving them some free medicine. However, most of these free prescriptions that are showing up in our offices are used for chronic conditions: birth control pills, anti-depressants, cholesterol-lowering agents, stomach acid-reducers, etc.

So what happens when your free medicines run out and you need more of this medicine for your chronic condition?

Why, you call your doc and ask for more samples of this medicine that you are now used to taking, of course! Except now, there are no more free samples. No problem, your doc will just call in a refill for you to your local pharmacy. This is when the expensive reality of free drug samples kicks in. The following are some examples of just how much your “free samples” are really going to cost you by the end of the year (all prices from Costco):

Example 1
Loestrin 24 birth control pills: $72/month x 12 months = $864 ( – 3 FREE SAMPLES = $216) = $648 per year

Microgestin (generic) birth control pills: $21/month x 12 months = $252 per year

Example 2
Lexapro 10 mg anti-depressant pills: $92/month x 12 months = $1104 ( – 3 FREE SAMPLES) = $828 per year

Celexa (generic) anti-depressant pills: $7/month x 12 months = $84 per year

I could cite a dozen more examples, but that would be boring for both of us. You get the idea.

Suffice to say, Big Pharma wouldn’t be handing out free samples to doctors’ offices if it didn’t earn them a very tidy profit. So the next time your doc offers you some free samples of a prescription medicine you are likely to be on for a while, ask her if there are any similar generic medicines available instead.

Leslie Ramirez is an internal medicine physician and founder of Leslie’s List, which provides information that enables all patients, but especially the uninsured and underinsured, to find more affordable medications and health care services.

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Comments

jsmith
First one’s free, kid. Next one you pay for.
http://www.drmintz.com Matthew Mintz, MD
Excellent post. However, it’s a little bit more complicated. The assumption is that the patient is paying out of pocket for their medications, which is usually not the case. Also, in both examples, a generic medication was equally effective and safe. This is not always the case. Additionally, many branded products give out coupons with the samples which discount your pharmacy co-pay, some with renewing discounts for a year (though not always the case so be careful). Finally, you need to consider how much your co-pay would be, which depends on your insurance and your formularly.
Using cholesterol as an example, let’s say your bad cholesterol or LDL is 160 and your doctor tells you it needs to be under 100 based on your risk for heart attack and stroke. Simivastatin is generic and has been proven effective, but you will likely need the highest dose of 80mg to get to your goal (the higher the dose, the greater the likelihood of side effects). The generic (no samples) costs you $10 month at your local CVS. Lipitor will get to goal at a 20mg dose, but at a price of $25 per month. However, I can give you a 4 week supply of the medicine to try (to make sure there are not side effects, etc.) and a coupon that will lower your monthy cost to $0. This will last for a year (at which point LIpitor should be generic). Using the branded product with samples and coupons just saved you $120 for the year, allowed you to try the med first, and gave you a drug that worked better with fewer side effects.
Samples do not help the poor or those without prescription coverage, and as a marketing tool for the drug companies they absolutely increase how much we spend on drugs (your example of generic celexa vs. Lexapro is a great example). However, they do have an important role and should be used judiciously by both patients and providers.
Sarah
Am i missing something, or does this post make no sense? If you’re a doctor, and you know your patient has no money, and you’re out of free samples, why would you call in a refill for the brand name if there’s an equally good generic version available? (Assuming that the patient is equally able to tolerate both the brand name and the generic versions.) Sure, a lot of things cost more if you don’t think them through.
“So the next time your doc offers you some free samples of a prescription medicine you are likely to be on for a while, ask her if there are any similar generic medicines available instead.”
Again, how is it cheaper for me to pay $5 for the generic drug, instead of taking the free sample of the brand name, which is free? I can always ask about the generic drug after i’ve run out of samples. Whereas if i take the generic now, i don’t know that there’ll be any free samples available later. And if i don’t tolerate the generic and am eventually forced to pay for the brand name, well, wouldn’t that happen either way?
I’ve had friends who could not afford to pay any money for medication, who survived on free samples alone, and who would not have taken any medication otherwise. I really thought this post would be about an increased cost to patients as a whole, rather than to the individual patients who take free samples. As it stands, i feel like i must be missing something. Please let me know what that thing is.

http://www.leslieslist.org/ Leslie Ramirez
My point was simply that rather than get started on a brand new (and costly) just-released and heavily promoted drug, why not start out (or start your patient out) on a medicine that you know will be affordable for the long haul? My experience is that when a patient is on a birth control pill or an antidepressant medicine (for example) and she is tolerating it well, she is often loathe to switch to something else and ends up going ahead and paying for it. Recall that another point is that the medicines being “sampled” by drug reps most often are meds that they expect a patient to be on (and pay for) for years.

Sarah
Indeed, i believe i do understand your point. I guess what i take issue with is the fact that you start your article with the unstated assumption that a patient _will not switch_ from a generic to a brand name. I’m sure that is true for many patients, but it’s certainly not the case for every patient. How hard would it be for the doctor to simply _ask_ the patient about their preference, rather than making assumptions?

TrenchDoc
There are other costs you have not considered as well.
1. Doctor time spent being interrupted and sales pitched. I counted 17 sales reps on one typical afternoon including 2 separate sales rep visits for Levitra.
2 Doctor or staff time it takes to locate and sack up samples in a busy multiprovider clinic.
3. Staff time wasted telling sales reps no to multiple doctor invitations to breakfast lunch dinner snacks etc.
4. Staff time wasted fielding calls and drop in visits by patients for more sample refills.
5. Doctor time wasted trying to understand and keep up with all of this information about what insurance company covers what drugs.
TrenchDoc
Oh I forgot to also mention that sales reps also take up chairs in your waiting room and occupy valuable parking spaces.

CP
1. It’s your practice and nobody obligates you to see these reps – why do you?
2. Samples are provided as a courtesy to the physicians and as some stated already can actually help your patients
3. How much time is really wasted on this? Why not post somewhere that it’s your policy not to see reps under any circumstances. Better yet, as I’m sure you’re aware, you can always place your name on the opt out list and no reps will ever bother you again. BTW, when I was a rep, I had plenty of doctors who asked me to set up lunches and had specific expectations as to where the food should be purchased from.
5. Shouldn’t that be part of the physician’sjob? Helping the customer (patient) – business 101
“taking valuable parking spaces..” – LOL – that’s the argument?
Anonymous
Why not opting to be on the no-see list then?
Anonymous
So why are not opting to be on the no-see list?

http://www.silvercensus.com/ Steffan Lozinak
I have to agree with the idea of starting with free samples and switching to the generic after the samples run out, if this is possible. This accomplishes a few main goals, helping the patient save money, and costing big pharma money… I really can’t stand the pharmaceutical industry.
Sarah
Hmm… i keep trying to ask a question that won’t post. It was my understanding that the two of the drugs mentioned in the article, the brand name versions of escitalopram and citalopram, are misrepresented as the same drug. (Let’s see if my question will post if i don’t mention the brand names.)
Sarah
By the way, i appreciate TrenchDoc’s enumeration of the hidden costs of free samples. (But how come he/she can use a drug name in his/her post, and i can’t use two drug names in mine? Boo!) LEXAPRO AND CELEXA
LauraNP
I call my pharmaceutical company reps all the time and ask for more free samples. They actually come and see me and give me piles of samples. Of old meds, new meds, actually, whatever I ask for. I’m a psychiatric NP and I get depakote, any antidepressant, any antipsychotic I want, not just the new meds. That’s why your pharma rep gives you a business card! So you can call them for more samples! I’ve had patients getting free meds for years. Maybe you guys never knew you can simply call and get more???
http://drkeegan.blogspot.com/ Keegan Duchicela
LauraNP,
We are just as susceptible to direct-to-consumer advertising as our patients. Any doctor (or nurse) who says they aren’t swayed by ads, free samples, or attractive sales reps is fooling themselves. Being pharm-free is a pretty standard concept among the current crop of medical students and residents. Some doctors of more mature generations have had a harder time kicking the habit.
We don’t see pharm reps because of all the reasons Trench doc stated above. Similar to how we fast forward through commercials on our DVR, we shouldn’t willingly expose ourselves to biased information. Well, where should we get our info from then, you might ask? Less biased resources include Uptodate, Prescriber’s Letter. While not totally free of influence, common sense tells you they’re far better than a drug rep.
TrenchDoc
Some of us have partners who love drug reps because they like the free lunches and do the dinner talks for consulting . So some compromise is necessary to keep the peace in the office. So the only drug reps I will see are the ones that look like old girlfriends!
Liza
Additionally, the Loestrin example is flawed because Loestrin has a customer card so that if your insurance doesn’t cover some of the cost, you can get the meds for $24 max. No one should be paying $72 a month for Loestrin24.

allen
Come on people! Why are we picking at the details. Those that defend this practice fail to recognize the influence of this practice. I quit seeing drug reps 2 years ago and the rest of my partners did not. My generic utilization skyrocketed as the concern for the patient affordability and compliance were the only factors in this. Run the example with 6 months of free samples and you still end up behind. The nit-picking of the example shows the truly insidious effect of Big Pharma marketing
If you really want to save “poor” people the cost of needed proprietary meds (those w/o generic availability) then take advantage of the patient assistance programs that are available so you get them that year of medicines.

http://drpullen.com Edward
The other part of the issue here is how this policy influences physician behavior, and increases the cost of healthcare in the US. This is well documented, studies show that oveall drug costs for patients using offices that accept free samples are higher than in offices that don’t. A discussion at http://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.1000074 and many others.
LauraNP
In response to Keegan, I didn’t say I get my information from the pharma rep! I said I get the pills from the rep. I too use uptodate and I subscribe to prescriber’s letter. There is no reason not to call on your pharma rep when you need free samples. That’s all I said. I get my continuing education from non-pharmaceutical research. Yes you can use the pharma rep for samples without being “swayed” by commercials!
Sue
The situation is TOTALLY different for asthma drugs. When short acting beta agonists had to switch from CFC ro HFA ( don’t know how spraying something into your mouth could hurt the ozone layer, but whatever . . . ) there suddenly was no generic albuterol. There are no generic high dose inhaled steroids or combination steroid-long acting bronchodilator med. There are no generic leukotriene receptors inhibitos. Especially when you’re prescribing something as hands-on as an inhaler, I firmly believe compliance is much better if they walk out of the office holding the inhaler I just taught them how to use.

visibility9
You can get generic albuterol-the thing is, since the HFA requirement, it is closer to 30 dollars when it used to be 12.

http://hotmail.com Art
With 75% of prescriptions now being prescribed as generics and the patents of most other drugs running out in the next few years, someone may ask soon why we need hundreds of different birthcontrol pills and why brand drugs have “hit a wall” and can only develop “new and improved” versions of existing drugs.
Are they really improved and with scores of different drugs generically available are they all equal in quality?
So with all types of Blood Pressure drugs now generically available which is the best one for each of us and how do we know? Or do we just stay with the one we are on when it goes generic with a “if it ain’t broke don’t fix it”!

ninguem
“…..75% of prescriptions are generic…..”
Is that factoid accurate?
If so, and assuming some of the branded drug prescriptions are necessary, or there’s no generic equivalent, how much room is there to switch to generics? Maybe ten percent of prescriptions written?

http://www.drmintz.com Dr. Matthew Mintz
Do drug reps/free samples…
-influence doctors? absolutely
-increase prescribing of non-generic meds? absolutely
-contribute to health care dollars spent on meds? absolutely
-bad for patients? it depends.
It is true that whenever a generic medication has equal safety and efficacy as a branded medication, the patient and public benefit when a generic is used. However, just because there are generic medications available, does not always mean that they are the best choice.
A good example is type 2 diabetes. The RECORD study looked at cardiovascular safety of the much maligned drug Avandia (showed it not to increase risk of CV death or hospitalization-something the media continues to ignore). The study took patients on a generic diabetes medication (either metformin or sulfonylurea) and randomized them to either an expensive, branded diabetes medicine (Avandia) or the other generic. Patients in the Avandia group who still had uncontrolled diabetes on Avandia + one generic could add the other generic. Patients in the other group who were uncontrolled on both generics had to go to insulin.
In addition to showing no difference in cardiovascular safety (primary endpoint), the patients in the Avandia group had better diabetes control, less weight gain, better cholesterol profiles, less hypoglycemia and less insulin use.
In other words, though it certainly costs more money, (in this study) it was better to add Avandia then sticking with only generics.
Though there are plenty of instances where a branded medicine is probably prescribed far too often, since a generic medicine that is just as safe and effective exists (Lexapro), there is still a huge need for branded medications. “Skyrocketing” use of generics will certainly lower costs, but may not be in the best interest of patients.

ninguem
The drug companies probably find their marketing money is better spent bribing insurance executives and benefits managers.
Then they can force the doctors to write the favored drug, by fiat.

Devon Herrick, PhD National Center for Policy Analysis
I made a similar argument in my report “Shopping for Drugs: 2007” on ways patients can lower their prescription drug spending (www.ncpa.org/pdfs/st293.pdf).
I found some instances where prescription costs could be lower up to 95% by switching to a generic, purchasing double strength tablets in bulk (quantities of 90 to 100 by mail) and splitting half.

http://www.leslieslist.org/ Leslie Ramirez
Dr. Herrick.
Just wanted to say I read your white paper, “Shopping for Drugs: 2007″ and referred to it many times when I created LesliesList.og. It is very well done and comprehensive and highly recommended reading for all interested in how to help save patients money on medicines. Thank you for your excellent work!

ninguem
Same here. What Leslie said.
I’ve got a copy of your “Lives at Risk” book in my library next to my desk. Excellent work.

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