The issue of generic versus branded therapy arises when considering how to optimize a glaucoma patient’s treatment beyond first-line therapies. Recently, a panel of eye specialists and healthcare policy experts debated the merits of both medication types and related insurance matters for The American Journal of Managed Care.

When Should a Patient Move to Branded Therapy?

Moderator Neil Minkoff, M.D. asked his peers when they know a generic therapy has failed a patient and a switch to a branded agent is needed.

Terri-Diann Picerking, M.D. said she looks for a reduction in intraocular pressure (IOP) of at least 20%-30% after 2-3 weeks of using a generic agent. If this is achieved, she’ll keep the patient on the generic; if not, she will either switch to another class of generic or appeal for a branded agent.

Minkoff then asked Pickering whether an appeal is necessary, since many insurers have most drug classes cataloged electronically, which should reduce processing time. Unfortunately, this hasn’t been Pickering’s experience.

Nathan Radcliffe, M.D. said that after a drug’s first 3-5 years on the market, he’s encountered lesser issues such as the need for prior authorization—“like a box needs to be clicked.” But the first few years of a new therapy can be very cumbersome. Furthermore, he’d like to have a system of treatment to make things more efficient, but can’t because often two patients will respond differently to the same therapy. 

“It is a master class in human variability to treat glaucoma because everyone will have something different going on,” he said. “And that’s why we end up on all these different regimens, despite [the fact that] we’re just treating one disease with one goal, which is to lower the pressure. It really is patient-driven. We need all the tools we have.”

How Effective Is Medicare for Glaucoma?

As glaucoma prevalence increases with age, Medicare factors heavily in disease management. Minkoff asked the experts their views on Medicare tiering, and out-of-pocket costs for people potentially facing blindness.

Maria Lopes, M.D., M.S., who has experience in medical policy development and implementation, noted that generics, when available, often pose very little cost to patients, but she has found that when generics are available, new drug brands often don’t make it to the preferred tier. If the drugs are covered, they’re typically in a non-preferred tier that may involve a 30% copayment, which many people cannot afford, especially if they’re already on multiple medications.

She went on to describe the difficult appeal process for a medical exception, when providers justify the need for preferred status of an otherwise non-preferred drug after other options have been exhausted. “That is a barrier and that takes time away from providers,” said Lopes. The difference in tiers is also expensive for patients. “If patients can’t afford it, then this medical exception kicks in.”

Lopes also noted that a drug may not be covered if it hasn’t yet been reviewed. There is also Medicare’s moratorium on new drug classes, which extends until a new year arrives, as well as a new formulary (list of medications) for product review. To overcome this barrier, a medical exception would have to be approved.

Medicaid, Private Insurance, and Peer-to-Peer Review

Also speaking from an administrative perspective was Kevin Stephens Sr., M.D. Stephens explained that Medicaid is state-driven, with a formulary based on that state’s budget, and serving a different population. In group insurance, on the other hand, the employer often pays the cost of the plan, with premiums based on disease burden of the employee pool. This is much harder to manage, said Stephens, since the employer is concerned about how much and for what the insurer is paying. And this, he said, raises another issue: there are different plans—Medicare, Medicaid, and commercial insurance, and all are managed differently.

Stephens also commented that the peer-to-peer review process is an effective and underutilized tool for avoiding the appellate process when switching medications. A provider can ask to speak to the reviewing physician and, many times, convey information that paints a more complete patient picture than a written form, or even medical records, can. This process is especially useful in “unusual, extraordinary cases.”

*AJMC. (2022, February 28). Considering Generic Vs Branded Therapy for Glaucoma [Video file]. https://www.ajmc.com/view/considering-generic-vs-branded-therapy-for-glaucoma