The impact of hiding medication costs from patients

Always covered by an employer health plan, I had never given a thought to prescription costs – my medications had been covered by moderate copays. This changed when I retired and enrolled in Medicare (and a Medicare Part D plan).

Just prior to retirement, my eyes suddenly began tear and swell so much that it impacted my vision. The eye doctor diagnosed an allergic reaction and prescribed prednisone drops to reduce the swelling and antihistamine drops to combat the reaction. The antihistamine drops required pre-approval by my employer’s PBM, which was granted. Per my employer plan I paid a relatively small copay for each prescription.

Three weeks later, on a follow-up visit, the doctor recommended that I continue the antihistamine drops for the duration of the allergy season. But I was running out and had to refill the prescription. Now I was on Medicare so I checked the cost of the drops on the website of my Part D provider. It was $279. Could this be?? Oh indeed it could — and I had a high deductible and would have to pay all of it!! Of course, if I continued to need the drops, the plan would eventually assume more of the expense – but even then the cost would be high – to the plan, even though not as much would come from my own pocket.

I was somewhat puzzled. I did not have an exotic illness requiring a specialized drug and it seemed that there should be a less expensive alternative. After a conversation with my doctor, it turned out that there were, in fact, two reasonable options: one a prescription which was ½ the price of the current prescription; the other a medication that had previously been script-only, but was now available OTC – the cost for this was $14.79. He suggested that I experiment with the alternatives to see if they were as effective as the current drops. Fortunately, the $14.79 version was just fine. Of course, it might not have been, but it was. But had I not asked, it would not have been offered. And had I not had a plan that exposed the cost of the expensive prescription, I would not have asked.

A few weeks later, I had a similar experience while visiting my 92 year old mother. In response to a complaint about stomach pain, her doctor had prescribed an extremely costly medication. She was required to pay $80 for the first prescription and then $184 when she tried to renew it. She decided that it hadn’t really helped much anyway and decided not to renew. But I realized that had the cost not been so high, she would have ordered it.

These two experiences led me to wonder about the impact of “hiding” medication costs from patients (as my employer plan had essentially done), and of doctors not being sensitive to cost issues until prodded by patients. Of course, sometimes the more expensive drug might well be necessary – but surely there must be many instances in which money could be saved by balancing therapeutic need and cost.

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  • Anonymous

    Why didn’t your doctor recommend the over the counter medication in the first place?

    • Carol Levy

      I find it rare that docs recommend OTC. They are accustomed to ‘name’ meds and seem to go that way as a matter of vourse and habit.

  • Markus Unread

    It’s less a matter of the price being hidden. It’s more about drug companies pushing newer, still patented, variants of older less-expensive drugs.  If one were to go to an MD five times in five years requesting a muscle relaxant, there’s a very good chance that the result would be three or four different prescriptions: each “newer” than the last.  Newer is always more expensive in the world of prescription drugs.  Unlike what the sales people say, it’s not that the new drugs have less side effects. It’s that the new drugs are new, and the acknowledged side effects list hasn’t had a chance to grow to meet reality.  Since drug response is so variable from person to person, “new versus old” is often not equivalent to “better versus worse” – especially when they are talking about neurologic, immune or psychoactive drugs.
    It’s no surprise that the sales people push a drug hard until the patent runs out – then it’s no good any more.  Why try diphenhydramine ($3/100) when you can be taking new Ataxavantistihistaphex ($5 each)?

  • Carol Levy

    I need Nexium but, because I am on Medicare D, it will put me into my ‘donut hole’ and I do not have the cash to pay the over 2,000$ necessary before I can get out of it.
    A few years back I encountered a very interesting dichotomy.
    I went to a pharmacy to put in a prescription for a friend.  I asked the price.  He responded, “It is (about) $500.00 if your friend does not have insurance.  If she did the drug costs (about) $300.00 and then of course her insurance will pick up some of that cost.”
    So, if I was poor and could not afford insurance the drug was more costly than if I did.  Same drug, same company, priced by the company.
    It is not just an issue of ‘hiding the costs’, it is an issue of fairness and legitimate pricing by the pharmaceutical companies.
    (And for D thankfully health care insurance reform, though slowly, will ultimately phase out the ‘donut hole’ completely.  This year there was some help by increasing the ‘out of pocket’ amount before the you fall into the ‘hole.’)

  • Robert Bowman

    One of the saving graces given too few physicians in primary care and a few other areas, is the fact that physicians will likely continue longer in practice at least part time – because of such poor coverage involving Medicare and plans that are not associated with health systems or employment.

  • Anonymous

    Thank you for the post. I will shortly be representing Medicare Advantage and Part D plans. The Part D plans are particularly difficult to fully understand by either the agent or beneficiary. Your story is an excellent example of why I need to study the plans (there are many alternatives out there) and I really need to engage the consumer about there current medications and encourage them to talk to their doctor. Often times there are alternatives, but the consumer or his advocate needs to fight for the information. Medicare and PDP are a terrific value for seniors, we all just need assistance in navigating the system.

  • Personal Failure

    Nobody’s hiding the cost of the medication from the patient. That’s absurd. The patient and/or their employer pays for insurance, which in turn pays for prescription medication. When a doctor prescribes a medication, the patient assumes that is the best medication for their condition. Why would knowledge of what the insurance company pays for it change their mind about taking it?

  • Philip W Chao

    I think the patient should be informed when they pick up ANY prescription how much was paid for that and by whom.
    Just to give an example – when the nurses association of NY gives you a pill box paid for by medicare they charge 32 dollars – the same pill box on Amazon is 4 dollars.  Why does Medicare get billed 8 times the cost of the product?
    (well it is probably cheaper than 4 – since similar pill boxes are in the dollar store also.)

    Just an example where the cost of medicine needs to be more transparent.

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