Divided doses

Shaunta Grimes

Monday, Oct. 25, 1999 | 11:18 a.m.

Some Nevadans are finding Health Plan of Nevada's six-month-old policy of paying for double dosages of certain prescription drugs a hard pill to swallow.

Since April the Health Plan's patients taking Celexa or Zoloft for depression or Lipitor to help reduce cholesterol have received prescriptions that provide half as many pills in double the dosage and are told to split the pills themselves using a tool provided by the insurance company.

The VA Southern Nevada Health Care System has had a similar program in place for years for its 26,000 enrolled members, said Gregory Steelhammer, chief of pharmacy for the system.

The practice was initiated as a way to keep drug costs down for the Health Plan's 233,000 Nevada members, Jenny Des Vaux Oakes, spokeswoman for the plan, said.

Steelhammer said similar funding issues are behind the pill-splitting practice at the VA health care system.

The double-dosage strategy saves money, because drug companies sell medication in single and double dosages for close to the same price, Oakes said. How much money it saves the insurance company hasn't yet been calculated, Oakes said. The VA system saves at least $650,000 per year by requiring their members to split their own medication, Steelhammer said.

Complaints about pill splitting from patients and doctors have reached the state Pharmacy Board, which at 9:30 a.m. on Nov. 4 will consider a change to regulations that will stop insurance companies from refusing to pay for single-dosage prescriptions.

If the rule is adopted, doctors still will be able to prescribe double-dosage pills, but insurance companies will not be able to refuse to pay for prescriptions of single-dosage pills.

Some pills like Celexa and Zoloft are not difficult to split, because they are scored. But some pills like Lipitor have a coating that holds them together and when patients try to cut those pills, "they basically explode, fall to pieces," Jack Paige, investigator and inspector for the Nevada Board of Pharmacy, said.

Even with scored pills, patients with a physical handicap such as poor eyesight or arthritis can have a problem breaking the pills evenly, which can also cause the medication to crumble.

The coated, unscored pills that patients are required to split are medications that do not necessarily need to be split evenly, Steelhammer said. "As long as they get the whole pill every two days, even if the pill is in pieces," he said.

Jeffrey Cichon, president of the Clark County Medical Society, noted it's not that clear cut. In a small number of cases it might be all right for people who have trouble cutting the pills to take a full pill every other day. But it's something a doctor should decide, and it's dangerous for patients to take that matter into their own hands.

"Medications are given on a regular schedule for a reason, to keep a steady flow in the blood stream," he said.

Health Plan of Nevada has allowed doctors to request single-dosage pills for patients who are not able to manage the pill-splitting tool, Oakes said.

"We've always understood that there may be patients that this might be a problem for," she said.

Doctors wishing to prescribe single dosage pills to Health Plan of Nevada patients need only to call in a request to the pharmacy's phone-in division. "All a doctor has to do is pass on the information," Oakes said.

Cichon does not buy Oakes' claim that getting approval for a single dosage prescription is as easy as making a telephone call.

"This is the first I've heard of it," Cichon said.

As far as Cichon knows, most Clark County physicians are not aware that they can ask the health plan to pay for a single dosage prescription.

"Even if they are, it has been my experience that the insurance company will tell a patient, 'All you have to do is have your doctor write a letter,' and we have a file already with four or five letters," Cichon said.

Las Vegas resident Sandra Sherlock, 65, is one resident who is angry about the whole situation.

She said it doesn't bother her so much to split medication that is scored for the purpose, but her prescription for Lipitor is not scored and she has ruined several pills trying to cut through the coating.

Sherlock said she has saved the pieces of the destroyed pills and plans to bring them to the Nov. 4 meeting.

"I might sacrifice another pill to show them in person what happens when you try to cut these things," she said.

Patients must have used 75 percent of their prescriptions before they can be refilled, Paige said, meaning that if too many pills break, patients may end up short of medication.

Oakes said even though Lipitor is not scored, Health Plan of Nevada provides a quality pill-splitting tool and she has not heard any complaints.

Oakes may not have heard any complaints, but State Assemblywoman Vivian Freeman and Pharmacy Board Executive Director Keith Macdonald have.

Freeman said she has received several calls from Las Vegas residents about pill splitting and feels strongly enough about the issue that she is willing to support the new regulations and perhaps propose a bill in the 2001 Legislature to address it.

If the new regulations were put into law, then insurance companies wanting to change it in the future would have to go to through the Legislature rather than the controlling agency, the Pharmacy Board in this case, she said.

"I think this is an important issue," Freeman said. "I have arthritis myself. It's not bad but I'm getting older."

She would not say how many people called her, but noted it was enough to make her believe the issue is important to Nevadans.

Macdonald said his office has received at least a dozen calls from patients since last spring and several pharmacists have reported patient complaints to the Pharmacy Board.

If the regulation is accepted by the board on Nov. 4, the issue will go to the Legislative Counsel Bureau where the rule will be drafted for final acceptance in December.

"The law won't be in effect until at the earliest January 2000," he said.