The patient was angry. His pain management doctor had written a prescription for a new pain medication and the patient expected it to be covered by his insurance. It wasn't, and the patient was stunned by the drugs $320 price tag. There was no way he could afford the drug and he went home empty handed and in pain.
Stories such as this are not at all uncommon. Prescription coverage varies widely from one insurance to the next and seems to change daily. It is impossible to keep current. Previously covered and once inexpensive generic medications become uncovered and expensive seemingly overnight.
A week ago I wrote a prescription for doxycycline, a 48 year-old antibiotic that a few years ago had a cash price of $4 at Target and Wal-Mart. Imagine my surprise when the pharmacy called saying it was not covered by insurance and the cash price was now $65! How does that happen?
A few months ago a patient called asking for help with his sleep medication. His insurance would not cover generic Ambien and he could not afford the $85 his pharmacy charged for 30 pills. I had my staff check on what our cost would be if we ordered it ourselves. Our price- 100 pills for $3.10. The pharmacy was charging $85 for a medication that cost them $1!
100 mg Viagra tablets cost almost $30. Five 20 milligram tablets of the same drug from the same manufacturer, sold under the brand name Revatio, can be purchased for $4. When I asked the drug company salesman why this was he could not provide me with an answer.
There are many aspects of medical practice that are frustrating but medication costs and coverage are of particular concern. New drugs are always ridiculously expensive, with thirty day supplies of new medications consistently above $150. The prices are often concealed from doctors by sales people whose presentations focus on co-payments and discount cards instead of total costs.
What can patients do to navigate such a system? I am often confused and perplexed by insurance coverage of medications, how can a lay person be expected to know what to do? We are in desperate need of greater transparency in how medications are priced.
While we wait for that day to come here are a few recommendations-
1- Tell your doctor when a medication is expensive. There may be less expensive alternatives. My daughter was once prescribed a medication that cost $700 a month. The doctor was shocked to learn of the cost and changed to a more affordable option.
2- Shop around. Prices can vary widely from pharmacy to pharmacy. A few years ago I called several pharmacies to check their price for generic Prozac. The four prices were, $7, $11, $25 and $40 for a one month supply. Do not feel as if you do not have choices.
3- Ask for an inexpensive drug. For common conditions such as high blood pressure, diabetes and sinus infections there are usually very inexpensive options. Target and Wal-Mart sell a 30 day supply of many common generics for $4.
4- Use coupons. Web sites such as goodrx.com can offer sizable savings. Almost every brand name medication will have coupons on their websites.
5- Fight when needed. I recently had a patient who was taking a medication twice a day for chronic pain. It worked well but wore off in the middle of the day. I gave him a sample and suggested he try taking the medication three times a day. He was thrilled to report dramatic improvement so I sent the new instructions to the pharmacy. His insurance denied the claim saying they would only cover the medication twice a day. I wrote two letters and personally called the insurance but they did not budge. He appealed the denial all the way up to the California Board of Managed Care. The Board notified him yesterday that his insurance would be required to pay for the medication. It took more effort than it should have, but he won!
- Bart
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