A woman, 72 years of age, was recently diagnosed with type 2 diabetes. She has a Medicare plan. I don’t know her financial situation but do know she gets Social Security and has other retirement income. Her A1C was rising. We had recommended and taught lifestyle changes which she had difficulty with; she made some changes but not enough to lower her glucose. We added metformin which she did not tolerate, so we discussed one of the SGLT-2s. After hesitating, she agreed to trying one. We gave her samples, she took them. Her A1C lowered to the goal we mutually decided upon.
It was my impression her insurance covered her medication, but she did not fill the medication. She told us it was not covered, but she tolerated the medication so well she wanted to continue it. She asked for more samples. I told her I would give her one week to look further into it, but that was all I could do. We needed to come up with another plan, a long-term plan, which meant using a medication she could afford. She wasn’t open to making a medication change but said she would work harder on making food and activity changes. I let her know that was her choice, we could see how she responded. When she returned, her A1C was again rising. She asked me for samples. I once again told her I could not give her more samples; we needed another plan. I recommended other glucose lowering medications, but she again told me she would try harder. It was a busy day at the office. I was running a bit late with my patients. I thought I heard her talking with one of the medical assistants, and I thought I heard pills rattling in her purse. I did not feel it was appropriate to confront her or the medical assistant at that time.
The day of her return visit I pulled my staff aside and discussed that if the patient asks for samples, we could not give her samples. She had received samples and samples are not a long-term solution for someone who needs a medication on a regular and most likely long-term basis. The medical assistant who I thought gave her the medication told me she had given her samples at the past visit, as I thought. I felt confident we had a plan. We had communicated and were all on the same page.
The patient came in; her A1C was not in target range. I told her she really needed to add a medication. Since she tolerated the one SGLT-2 but it was not covered, we should look into another. She then told me, “Oh, it’s covered, it’s just that the co-pay is too high.” I asked her the price, she told me what it would be for 90 days. It was actually one of the lower co-pays I see. I broke down the price per month, which she she agreed was doable. She left the office without samples and agreed to fill her prescription. No one in the office gave her samples. I don’t know if she asked, but they did not.
She returned. Was taking her medication, her A1C returned to her goal and she did not ask me or anyone in the office for more samples.
- Samples are to try a new medication to see if the patient tolerates the new medication and if it works effectively in the patient. Sometimes samples are given for an emergency, such as if the patient runs out and can’t get it in time for their next dose — there are many reasons, but long-term it is not a solution.
- Medications are and can be expensive whether covered or not covered. Even co-pays can be or seem expensive.
- Discuss sampling with staff. Offices should have a plan or policy in place for sampling and all staff members should know and follow this. For example, only the provider can give the samples.
- Communicate. Communicate. Communicate. Communicate with your patients AND your staff when you know there is a subject that includes them all so you are on the same page.
- Food for thought. Does sampling (oversampling) play into the high cost of our medications?
Joy Pape, FNP-CDE
Medical Editor, DiabetesInControl
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