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Old 08-15-2008, 11:25 AM   #1
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Confused089 HB User
DAW or "do not substitute" and insurance question

I have a question about DAW (dispense as written) or "do not substitute." My insurance [Steve & other Anthem BC members - hoping you can chime in...] has a $500 deductible for brand name, then a copay of $35 + the difference between the cost of the brand name and the generic]. Reps have gotten confused about this before and told me I just had a $35 copay - their confusion cost me a lot of money! I got the $500 deductible taken care of, expected to pay $35, and wound up paying over $300 for a brand name b/c they got mixed up. Not fun - over $800 down the drain!

I can't figure out if DAW or "do not substitute" might help me here - the benefits booklet isn't clear on this issue. If the doctor writes DAW or do not substitute, what is the significance in terms of insurance costs? I realize this may vary by plan but curious about what DAW means to insurance co's.

Steve, I know you take a special liquid oxycodone SA med -- is this a DAW, PA (don't think so after reading your post], or is it on their formulary?

Also, as far as I know, no one is producing generic oxycodone ER anymore, but Anthem lists it as a generic?? Can't figure this out either....

Thanks for any help...

 
Old 08-15-2008, 11:52 AM   #2
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Re: DAW or "do not substitute" and insurance question

Not sure about the DAW and your insurance but my insurance has me pay a $15 copay for brand. No deductible. No difference between copay and full price. I do know that some insurances will consider brand oxycontin as a generic because there is no other choice but brand. Did that make sense. Actually I should try pursuing this with my insurance as I take two different strengths which equals $30/ month just for my oxycontin. I can't imagine paying the difference in price s that would easily be a $100-$200 for each prescription. I'd be moving on to methadone.

I hope Steve or someone else with Anthem can chime in and help you more.~Mush
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Old 08-15-2008, 12:39 PM   #3
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Re: DAW or "do not substitute" and insurance question

Hi Confused,

I cannot answer about the Anthem insuance, but as far as the generic Oxycontin (oxycodone SR), there are no more generics for Oxycontin. Purdue (the maker of Oxycontin)won their appeal and patent back until 2013. So, until then, only brand name Oxycontin is available. You might still be able to find the generics in some pharmacies until they run out of their supply of the generic brands. Other than that, only brand Oxycontin is available.

Shay

P.S. I forgot to add that any patients on Oxycontin must have the doc write DAW on the script in order for the insurance to pay. I learned this while I was on Oxycontin back in January (after Purdue won their patent back). I've since switched to Methadone, which has helped me tremedously. I could have stayed on the Oxy, but it wasn't helping that much with my pain.

Last edited by friendly_one; 08-15-2008 at 12:43 PM. Reason: add info

 
Old 08-15-2008, 06:56 PM   #4
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Executor HB UserExecutor HB UserExecutor HB UserExecutor HB UserExecutor HB UserExecutor HB User
Re: DAW or "do not substitute" and insurance question

Quote:
Originally Posted by Confused089 View Post

I can't figure out if DAW or "do not substitute" might help me here - the benefits booklet isn't clear on this issue. If the doctor writes DAW or do not substitute, what is the significance in terms of insurance costs? I realize this may vary by plan but curious about what DAW means to insurance co's.
It varies insurance by insurance, but most have gotten very similar to one another. At one time, if a Doc specified brand for whatever reason, insurance companies still treated it as generic costs. However, that has changed with just about all policies. If a Doc specifies brand, you automatically fall under the brand policy....Which is a separate deductible in your case, and the the cost difference which you outlined. I have Anthem...I don't have separate deductible, but I do have the same cost differential policy.

Some plans don't address brands @ all....For example, the State of Va plan (all state employees) mandates generics only, no matter what. If you get a brand, you must bear the full cost.

Each patient has to make the best decision they can based on the med's effectiveness and cost. In some cases, brand is doable, while in other situations, the cost just doesn't justify the means.

Quote:
Steve, I know you take a special liquid oxycodone SA med -- is this a DAW, PA (don't think so after reading your post], or is it on their formulary?
We take the same liquid in terms of content, but his is generic, while mine is brand. I take "Roxidcodone", also known as "Oxyfast." He takes the generic, or "Oxydose." In my trials, the brands are much more potent. I'm sure he'll chime in though and verify or not.

Quote:
Also, as far as I know, no one is producing generic oxycodone ER anymore, but Anthem lists it as a generic?? Can't figure this out either....
I'm sure their website and formulary printed materials just haven't been changed yet....But, the will soon. Also, depending on the region of the country, there is still some generic product in the pipeline, thus, another reason why it hasn't changed.

Hope this info helps.

Regards,

Ex

Last edited by Executor; 08-15-2008 at 06:58 PM.

 
Old 08-15-2008, 08:25 PM   #5
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niap HB User
Re: DAW or "do not substitute" and insurance question

I have to disagree. My doctor writes oxycodone sr 10mg on the tripicate perscription and I only have to pay my co-pay for brand which is $30. T he dr. does not have to write daw or no sub. The only reason why they do that sometimes is becausse you cant tolerate the generic, so then I would imagine your insurance company should pay the differancebecause it is medically nessicarry. Please exuse my spelling. Good luck though, please let us know what happens.


niap

 
Old 08-16-2008, 06:11 AM   #6
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Re: DAW or "do not substitute" and insurance question

Confused,

You would have to check with your HR person at work to know for sure. Or possibly call Anthem directly and ask for clarification. Many employers are now adding "riders" to their plans that state that a brand name drug, regardless of whether there is a generic available, will be handled just the same as if there were a generic available.

If this rider is on your employer's plan, then it won't matter if your doc writes DAW or no subs on the script. This rider is just one more way employers are attempting to keep overall premiums down. If there is no such rider on your employer's group plan, then a DAW or no subs may still not be enough. The doc might need to write a letter of appeal to Anthem and see what happens. It is strictly up to Anthem's utilization review board to determine if there could be an exception in your case.

Hope this helps a bit. I know it's not the best news, but at least it gives you a starting point. Hang in there. I hope it all works out for you. CMP/MM

 
Old 08-16-2008, 07:31 AM   #7
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Re: DAW or "do not substitute" and insurance question

Quote:
Originally Posted by niap View Post
I have to disagree. My doctor writes oxycodone sr 10mg on the tripicate perscription and I only have to pay my co-pay for brand which is $30. T he dr. does not have to write daw or no sub.
Your experience is policy driven....It all depends on your particular policy. Obviously, you have a very good one. However, most policies today have substantial penalties for brand dispensing, unless DAW is written on the script. Even then, they may make the policy holder go through a preauthorization process. As Cmpgirl says, Confused should contact the policy for specifics....All are different.

And, not to make things more confusing, but two people can have the same company, yet the rules are different....Just depends on what "level" policy they have....There are many different types within each carrier...And some are even "customized" for certain companies.

Regards,

Ex

 
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