Attention BlueCross BlueShield and Walmart: Put bisoprolol on your "preferred" medication list, PLEASE!

It's 7 pm on a Thursday evening following a very long day that included rounds, hospital stress exams, multiple hospital echo interpretations, an office loaded with a particularly complicated group of patients, then interpretation of more office echoes and nuclear studies. My secretary left too late at 6 pm, handing me notes on several patients who needed callbacks. As I heard the sound of locking doors and footsteps leading away, my desk began calling me. I opened the door and there were four 1-ft tall stacks of charts waiting (I swear I just unloaded it and left it clean on Tuesday evening). I signed off on stress ECGs and Holter reports, sorted more complicated issues into "the morning pile," and checked off tons of lab results.

As I finished my last phone call, I spied a lone piece of paper at the far corner of my desk. It was a familiar-looking fax transmission. As I looked more closely, my pulse rate increased dramatically, my pupils dilated, and beads of sweat popped out on my forehead, much like a character in a B-movie horror flick. Oh my gosh, it's a communication from BlueCross BlueShield regarding bisoprolol AGAIN! Plus, they NEVER give you a list of preferred options on the same piece of communication, which is completely annoying and could be easily remedied by BC/BS the way other companies have done. What about a check-box or at least a list of preferred options without having to consult a website, my IPhone, a hot line, a pharmacy, or phone-a-friend?

Well, maybe I exaggerated the above flight-or-fight response to a BlueCross BlueShield communication, but to say I'm repulsed by it really is an understatement. I'm writing this piece hoping upon hope that someone from the insurance company will read it and make a positive change for patient care. I hope I'll have the same success I had with BlueCross BlueShield of Alabama over a decade ago when an out-of-state patient passing through Glasgow, KY needed enoxaparin injections. BlueCross BlueShield wanted to pay $4000 for an in-patient admission instead paying for $400 worth of outpatient Lovenox. I faxed a letter immediately inviting their accountants to examine this issue and "voilà," the decision was reversed. I sent the happy patient out the door with a fistful of Lovenox rejoicing on his way in hopes to cheer on the Crimson Tide.

Why, oh why, do I love bisoprolol? Let me count the ways. Let's begin by stating the little known fact that it is approximately 100 times more cardioselective than any other beta blocker in its class. For my patients, this means less fatigue, less depression, less impotence, less wheezing, and less dyspnea on exertion, and it's almost the same jackhammer for heart-rate lowering that you get with atenolol. I also get really annoyed when someone suggests I change a patient to short-acting metoprolol because the half-life necessitates it be dosed multiple times daily to get the same heart-rate or blood-pressure–lowering effect in some patients. After a morning dose of metoprolol, that means, for some, essentially have no beta blocker on board for several hours in the afternoon until they dose up again in the evening.
I've made multiple switches in my practice to bisoprolol with wonderful success, so why would I not insist upon prescribing it? But "more important," from an insurer's perspective (and believe me, I know the bottom line is the MOST IMPORTANT issue for any insurance company), allowing bisoprolol on their preferred list will save BlueCross BlueShield DOLLARS! $! $! $! $! (Ah, I can literally hear the sound of ears perking up at this very moment.) I feel compelled to diagram this, however, so as to allow for the same easy conclusion that came with my appeal for enoxaparin coverage. Please, someone fax this piece to the accounting offices of BlueCross BlueShield. 

I am the first to admit my opinion is based on anecdotal experience, but the early bisoprolol studies were objective and fascinating when you read about how cardioselectivity was actually measured and how it resulted in better tolerability. Although not everyone needs bisoprolol, especially those with marginally low heart rates or those who suffer from migraine that might respond better to propranolol, it's been my "go-to" beta blocker with very little hassle for nearly two decades.

Now for a more professional appeal: Clearing my throat and with a straight face, I'm asking you: "BlueCross BlueShield, will you please make bisoprolol a preferred medication? I can save you a $50.00 office visit today if you call me by 1 pm, as I have had to schedule an appointment just to discuss the switch with a patient to your 'preferred,' less cardioselective beta blocker." While I'm at it, I'm giving a shout-out to Walmart, which insists upon selling bisoprolol combined with that annoying HCTZ component for $4.00. Walmart, I would like a $4.00 option for PLAIN bisoprolol, please. What's up with that? Can someone explain an insurer's aversion to bisoprolol? It has been on the market long enough that it should be more affordable.

This is not a joke. This is a real issue that deserves a real solution, plus I was polite and even said "please." I'm waiting for my answer and so are my patients who are really just waiting for one thing: to feel better with less hassle. BlueCross BlueShield and Walmart, you can make that a reality.  

Your comments

	Attention BlueCross BlueShield and Walmart: Put bisoprolol on your "preferred" medication list, PLEASE!
	# 1 of 9	February 4, 2011 11:35 (EST)
	Kathy	I wish Walmart would add amlodipine to their $4 plan as well. They recently added amiloride. I don't know too many patients that take that.
	# 2 of 9	February 4, 2011 07:12 (EST)
	8dh	Quality of life was far superior on the non-selective carvedilol than highly beta1-cardioselective metoprolol in the largest comparison of two beta blockers done (COMET), in pretty sick CHF patients to boot.  I don't understand why you don't just go to long-acting carvedilol (if covered) - obviously not for frank asthmatics, but for everyone else, it is a superior option and more evidence-based. In COMET, it reduced the risk of fatal stroke by 62% compared with metoprolol, with reductions in other important atherosclerotic events.
	# 3 of 9	February 4, 2011 08:33 (EST)
	whufs	I had thought you were reasonable until now - I guess you are on the payroll after all.
	# 4 of 9	February 4, 2011 08:58 (EST)
	Melissa Walton-Shirley	In some patients, it's nearly impossible to get a heart rate down with carvediolol. I use it ALL THE TIME for heart failure and severe MR patients with great success though.   WHUFS, I don't even know who makes bisoprolol. I have no conflict of interest and take no money from drug reps but I smiled when I read your post.  I absolutely knew that would be the accusation because we have become so paranoid about physician drug company ties. No one is allowed to be enthusiastic about a device or a drug anymore just on the merits of their performance.  Don't blame you for being suspicious though since it is so rampant.  I would have wondered the same thing but didn't include that disclaimer because most of my readers are aware of my "no renumeration" stance.  Melissa
	# 5 of 9	February 5, 2011 05:38 (EST)
	whufs	My apologies to Dr. Walton-Stanley but ..... For those of us who welcomed metoprolol as an alternative to propranolol and then discovered atenolol as a cardioselective potent beta blocker and then observed the ridiculous non-sense of Toprol XL and the serum drug level graphs that company reps trumpeted around to convince gullible physicians to prescribe a drug for $40/month when a $4/month option existed this argument is hard to swallow.  Same goes for the "less glucose intolerance/metabolic syndrome" non-sense that Toprol/Coreg enthusiasts promote.  If heart rate slowing is important for angina, arrythmia or as an adjunct to vasodilator/diuretic therapy for HTN then atenolol is the drug of choice.  For non-ischemic cardiomyopathy carvedilol is the drig of choice.  For niche indications (cirrhosis with varies=nadalol, familial tremor=propranolol).  The theoretic arguments made in favor of bisprolol really don't pass the smell test and are very similar to those made during the early nineties promoting the XL formulation of an inferior beta blocker.  The current argument made against atenolol in not reducing stroke in systolic HTN is equally laughable because it is a non-physiologic indication for the drug to begin with.  If you encounter the rare patient who requires bisprolol for whatever reason then prescribe it (I would in that circumstance) but to expect the rest of us to widely subsidize that is a position I would ask you to reconsider.  And yes as physicians we need to start discussing cost else it will continue to be thrust upon us by parties who are less interested in patient care than we are.
	# 6 of 9	February 5, 2011 07:42 (EST)
	Melissa	Whufs, No need to apologize but I appreciate it very much. We've always wondered why bisoprolol was not on the "4.00$" Walmart list since it has gone generic, yet it remains a more expensive generic. Just curious as to the story on this, and I am passionate about bisoprolol because I have such positive experience with it and it's tolerability (just as you have with atenolol) I shyed away from atenolol a bit because of its negative affect on lipids and lowering of central aortic pressures. I still have many patients who are doing great on atenolol who I have NOT switched and reach for it when nothing else will control a heart rate. (atenolol vs. metoprolol in a holter driven study demonstrated that atenolol lowered heart rate an average of 10 bpm more /minute) I agree this discussion is an important one and appreciate your posts everyone! Melissa
	# 7 of 9	February 9, 2011 11:58 (EST)
	J. Salas, MD	Medicine practice is not about personal experience Dr. Walton-Shirley, but about applying science facts. Although it is required to individualize the treatment for each patient, it always must be supported with the best scientific evidence. Only this allows to achieve the best possible outcome.
	# 8 of 9	February 10, 2011 08:20 (EST)
	Melissa	J., that is exactly what I have done. I was very impressed with the cardioselectivity issue when I wrote a blog on this medication a few years back and the science has always served my patients well.  thanks for posting your view point and I agree with you. Melissa
	# 9 of 9	March 11, 2011 06:12 (EST)
	RecentAVR	I am interrested in your opinion of Bystolic (nebivolol) which I have been taking for a couple years, after metoprolol/Toprol-XL seemed responsisble for more fatigue and premature VC's.  It's more expensive, but FDA approval and European experience are other points in its favor.

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