Lisa Savage, MD


The Doctor's Corner

Fall, 2016

“Pharmacy Prices and other Drug Dilemmas”

Where to begin? Most of us have had “sticker shock” at the pharmacy cash register. My most recent experience was being told that my daughter’s topical medication for acne would be $600.00 for one tube of facial gel.  Obviously, I did not buy it, and we opted not to use it.   There is no justification for one tube of topical acne medication to cost that much. This is not a novel cancer drug, something to treat a very rare condition or anything for which the ingredients are precious and uncommon. No, it’s just stuff for acne, one among several alternatives for a condition that most people have had at one time or another. How on earth, we ask, can it cost that much? It doesn’t “cost” that much, we are just being “charged” that much. While I hate to be a conspiracy theorist, this is one area where I might not mind the title. Big pharmaceutical companies, seeking to maximize profit, will charge whatever the market will bear.

It surprises me, because at some point, consumers will just say no, as I did, and the sale is lost.  I wonder: does anyone pay that? Does someone plunk down six hundred bucks for a tube acne medicine? Do they sell ANY of this stuff in the US? Maybe others’ insurance coverage does allow for a reasonable price.  This is not a big deal when I can find a different acne medication or when my daughter’s complexion is OK without that medication. But, for some with chronic conditions, opting out of taking medication or taking less than what is prescribed can have serious consequences. And plenty of patients might not know that a less expensive alternative or a less expensive pharmacy might be available.

My staff conducted a survey of area pharmacies, such as CVS, Walgreens, Costco and Target. We inquired about “out of pocket” cost (i.e. cash price for an uninsured consumer) for a number of my most commonly prescribed birth control pills and menopause products. The variability between pharmacies was significant, with one brand of birth control pill costing twice as much at one pharmacy compared to another. The lesson here is to be a good consumer, don’t assume the price is similar everywhere, and do some research. We have a spreadsheet of what we found out, so feel free to ask for a copy. AND, realize that the “out of pocket” cost can actually be LESS than your insurance company’s required co-pay.  The pharmacist might or might not tell you that. Maybe they are on autopilot with checking insurance coverage and printing out what you owe based on your pharmacy benefits, or maybe there is some other reason not to give full disclosure on prices.  I don’t know, but I do know that ASKING about the “cash price” and comparing it to what your co-pay is might save quite a bit, depending on the drug and how long you are on it. My husband’s pharmacist nicely pointed out to him that a more generous supply of medication he takes daily can be purchased for LESS than his co-pay for a more limited supply. Go figure. Go ask.  Mail order pharmacies, if available to you through your insurance plan, might save some money, but the same principle applies in terms of the out of pocket cost vs. the co-pay.  Also, keep in mind that mail order is fine if your mailbox is in a temperature-controlled place, but if you’re like me,  your mailbox is outside where the temperature has soared to 106 here in Austin this summer. It’s not good for medications to be subject to temperature extremes, so be aware of that when opting in vs. out on mail order, even if the cost is better with mail order. A medication rendered less effective because of being baked in the Texas heat is not a good buy.
A question related to price issues is: Why do old-timey generics continue to go UP in price instead of DOWN? This is a not a normal trend in the marketplace for consumer products.  An old-timey electronic gadget that has been available for a long time and for which “knock offs” are available goes down in price.  If the technology is old, and the means of production have been paid for or have a stable cost, why does the price keep going up instead of going down or being stable?  I think the answer is an unnecessarily complex web of insurance requirements, vendor contracts and dare I say…an actual motivation by some to keep US drug prices unnaturally high. Also, drugs without a generic equivalent but that have been around forever (i.e. no new or fancy research & development costs) are going up, up, up in price.  A familiar example in my office are vaginal products for menopause changes. These come in cream, tablet and ring form. Seems like all of a sudden, patients are calling and telling us a 3 month supply is over $200, whereas it used to be much more affordable, say around $80. One patient’s 90 day supply was going to cost over $1000.00! When we did our survey of drug prices, we found her product’s “out of pocket” cost at one pharmacy was over $2000.00, while at another it was around $800.00. Either way, completely unaffordable, but notice the wide variation in price…from out of the question to out of the universe.  Why has the price gone up over a short time and by so much?  Why are manufacturers’ coupons only for insured patients? Might there be collusion between pharma and insura?  Also, why do common medications in common use require “prior authorization” from the insurance company?  We are being asked more and more to obtain “prior authorization” from the insurance company for older meds that we’ve used forever.  A colleague in dermatology shared this observation: her staff is being asked to get prior authorization for good old fashioned Doxycycline for acne. What???  Usually when we agree to “obtain the prior auth”, the insurance representative asks no questions, offers no explanation, and simply give us a “prior authorization number”. What is the point of that exercise? I will argue that the point is one more bureaucratic hoop to jump through, and many (including me) will simply refuse to keep jumping and opt for a different product. For example, we will not agree to request prior authorization for a birth control pill. So many are available, they all do a fine job, and our time is too limited not to just pick a different choice. I think this is the insurance company’s way of limiting choices and manipulating what is available to the average consumer.
 Another thing about drug prices: “free” is never free. You may not have anything due out of pocket for your birth control pills, but someone has paid money for them. The drug price is covered by your insurance premium, whether the premium is paid by you, your employer or your fellow citizens. It costs money to make, distribute and sell anything, and there is money paid for your medication. Insurance premiums are now uniformly obscenely high, and the cost of “covered” medications is part of the reason. It’s just a shell game, moving money around from one place to another. It’s designed to be opaque, so the average consumer is in the dark about real costs. As someone once said “if you think health care is expensive now, wait till you see how much it is when it’s “free”!

I want patients to know that if you ever experience “sticker shock” at the pharmacy, stop right there and don’t buy the product. Call us during office hours and we will try to find an alternative. Having your insurance company’s drug “formulary” list available will help. Sometimes the pharmacist can recommend an alternative.  While there is no rhyme or reason for some of the cost issues we face at the pharmacy, we will do our best to help you navigate the system and find something that doesn’t make you sick over the price!

Until next time,
Lisa L. Savage, M.D.

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