Hidden Medication Costs

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.

Costs of Care (Twitter: @CostsOfCare), where this post was originally published, is a Boston-based nonprofit organization that collects anecdotes from doctors and patients. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, and also because they unveil how commonplace and pervasive these types of stories happen.

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19 replies »

  1. In response to Christopher Stines’s comment “Anthistamines are really necessary if you have perenial rhinitis and urticaria.”
    According to, “instead of only prescribing antihistamine or steroid treatment, some doctors recommend people undergo allergy testing to determine what substances are resulting in perennial rhinitis. It is true that the most common allergies that cause this condition are to things like pets or dust mites, but there could be other causes. Exposure to certain identified allergens might be partially or totally eliminated rendering use of daily medication unnecessary. This possibility suggests it may make good sense to try to determine cause of allergies.”
    and according to
    “The most common causes are foods, medicines, latex, or infections. Insect bites and internal disease may also be responsible. The most common foods that cause hives are nuts, chocolate, fish, tomatoes, eggs, fresh berries, soy, wheat, and milk. Fresh foods cause hives more often than cooked foods. Certain food additives and preservatives may also be to blame. Medicines that can cause hives and angioedema include aspirin and other nonsteroidal anti-inflammatorymedications (NSAIDs, such as ibuprofen), high blood pressure medications (ACE inhibitors), or painkillers such as codeine.”
    So instead of relying on these drugs that might have side effects that only appear after a time, check out what the source of the irritation might be and remove it from the mix. Unfortunately, our society has bought into poison as our food source and poison to “remedy” the poison that our poisoned food source caused. I will be called a radical by these statements, but the addition of sugars and food coloring and the steroids and the hormones and the pesticides to the foods we eat are a fact. And when these cause adverse side effects, instead of removing them from our food source, we come up with ways to suppress the symptoms. Suppress, not remove. And now we are becoming aware of the symptoms that are developing from the means we are using to suppress the symptoms from the poison that laces our food source.

  2. Not only the hidden medication cost for the what about the hidden charges on the insurance planes. We recently had to hay about $3,100 in deductibles and extras for our child appendicitis.

  3. The original writer has hit a bullseye. Whatever the reason, the pharmaceuticals, the insurance companies, and the doctors seem to all be in this together. There is no need for this kind of expense and most people do not know about the expenses because we are only paying out of pocket so much (while paying premiums to the insurance company).
    Following is a very interesting article on how Vermont tried to change this Triage and how they were fought:

    Posted by Thomas Sullivan on June 27, 2011 at 05:05 AM in Medical Legal

    When filling prescriptions, pharmacies collect information including the prescriber’s name and address, the name, dosage, and quantity of the drug, the date and place the prescription is filled, and the patient’s age and gender. Pharmacies sell this patient identifiable (PI) data to what are known as “data mining companies,” who aggregate the data to reveal individual physician prescribing patterns and sell it primarily to pharmaceutical manufacturers.

    The PI data sold by the data-mining companies is stripped of patient information, to protect patient privacy. “Detailers” employed by pharmaceutical manufacturers then use the data to refine their marketing tactics and target sales to doctors.

    The Vermont law was adopted in the wake of New Hampshire enacting their law, and shortly before another similar statute adopted in Maine. The Vermont legislature passed Act 80 in 2007, intending to protect public health, to protect prescriber privacy, and to reduce health care costs through the promotion of less costly drugs and ensuring prescribers receive unbiased information.

    Section 17 of this Act prohibits the sale, license, or exchange for value of PI data for marketing or promoting a prescription drug, and prohibits pharmaceutical manufacturers and marketers from using PI data for marketing or promoting a prescription drug, unless the prescriber consents. Section 17 was effective on July 1, 2009. The statute adopts an opt-in approach, allowing prescribers to opt in to allow the use of their PI data for marketing purposes. The statute expressly permits the sale, transfer, or use of PI data for multiple other purposes (i.e. insurance, formular compliance).

    What made Vermont’s law unique from New Hampshire and Maine are the findings from the legislature. Specifically, the legislature noted that “the goals of pharmaceutical marketing as “often in conflict with the goals of the state.” The legislature also expressed its concern that detailing “caused doctors to make decisions based on “incomplete and biased information” because doctors “are unable to take the time to research the quickly changing pharmaceutical market,” and thus, must “rely on information provided by pharmaceutical representatives.”

    In addition, the legislature further found that “detailing increases the cost of healthcare and health insurance; encourages hasty and excessive reliance on brand-name drugs, before the profession has observed their effectiveness as compared with older and less expensive generic alternatives; and fosters disruptive and repeated marketing visits tantamount to harassment. The legislative findings further noted that use of prescriber-identifying information “increase[s] the effect of detailing programs” by allowing detailers to target their visits to particular doctors. Finally, the legislature noted that use of prescriber-identifying data also helps detailers shape their messages by “tailoring” their “presentations to individual prescriber styles, preferences, and attitudes.”

    Essentially, Vermont’s law attempted to correct what it saw as an unbalanced marketplace of ideas that undermines the state’s interests in promoting public health, protecting prescriber privacy, and reducing health care costs.

    When the Vermont law was first challenged in the U.S. District Court in Vermont, it was upheld, and found constitutional. As a result, the data mining companies IMS Health Inc., Verispan, LLC and Source Healthcare Analytics, Inc., along with the Pharmaceutical Manufacturers and Researchers Association (PhRMA) appealed to the First Circuit.
    Long story short:
    Because of the way the law was worded, the Court concluded that the law on its face burdens disfavored speech by disfavored speakers, and thus has the effect of preventing detailers—and only detailers—from communicating with physicians in an effective and informative manner. thus the law was overturned. Yet it seems clear that this practice of data mining continues to encourage the perpetuation of expensive drugs and hidden costs.

  4. Great post. It’s become increasingly important for physicians to remain aware of the cost of medications with relation to the patients they are prescribing them to.

  5. It is a routine carried out many times a day, every day, in most practices across the country. The patient arrives at the pharmacy to find that their new prescription is not affordable. The pharmacy calls the practice and it involves a message, possibly a chart pull, and a physician’s time to change the prescription. Most EMRs can tell what is or isn’t on a payer’s formulary, but few if any can offer a physician options based on the cost to the patient. It’s a major disconnect that costs every practice time and money.

    Walgreens has partnered with Epocrates to offer point of service (the exam room) information to physicians about the cost of prescription options. Why haven’t more big players followed suit?

    Great article!

    Thank you,

    Mary Pat
    CEO, Manage My Practice

  6. Medication can be very expensive, but there are often alternatives that can be cheaper. I decided to invest in some suppliments, and they have been brilliant. Free places online like questionmyhealth .com can give you a free profile of what items your body needs, and can help prevent serious deseases and illnesses. Definately worth a try before you end up spending loads on medication!

  7. I have no problem calling a pharmacist when the patient raises concerns with expenses and they are literally counting dollars to save. My issue is with those who have fairly decent insurance coverage that is turning down meds that are medically necessary and causing pts to lose time in beginning or maintaining use just because we are dealing with for profit entities that do not give a damn about the patient, just the CEO and the stock holders who need to maximize their dividend checks.

    And that is what this is about, insurers turning a profit. There are those who argue Medicaid does this too, but they have turned the system into such a bean counting exercise that they will hassle you about 2 meds that are just 9cents different per unit dose, and yet do not want to hear that formulation A is not as effective as B, just because A will save $2.70 a month for them, not being prospective and seeing that $2.70 spent today may save $2700 in future acute care needs when the pt crashes without medication B.

    Lack of vision, is why bureaucrocy fails all it touches when it sticks its hands into the health care field!!!

  8. I’m a pharmacist who works in a clinic setting. Makes it nice because the doctors can talk to us and we can speak with them about these therapeutic alternatives. While I would prefer it be done all electronically, we can discuss a patient’s situation and often recommend the most cost effective medication for a particular situation.

    While I sympathize with DeterminedMD, a discussion with the patient’s pharmacist can save a lot of problems down the road with cost issues or drug interactions. Maybe bump a few minutes from the drug reps and use this extra time to consult with us about the best medication therapy for these patients.

  9. how about the ongoing scam of albuterol, you had to buy ProAir at $40 an inhaler, so you can save the Ozone layer, because hey, all those inhalers out there are irradiating the planet, and now that we found out that is no big deal in the end, guess what Ventolin inhalers now cost after previously being 1/5 the cost?

    Yep, they are now just 4 dollars cheaper. And you wonder why pharma supported the bastard in the White House. Their money was well spent, and that is yet another reason to flip the bird at these bold faced liars behind PPACA.

    Not that any supporter wants you to know the truth!

  10. I had to buy 1.5 ml of Trazadone eyedrops when out of town at a CVS Pharmacy in Big Bear Lake, CA. They wanted $210.00 for the little bottle. Then, when I got home, my opthamologist looked up the real cost of the drops and it was a mere $50.00 per bottle.

    I contacted CVS Pharmacy about it and the representative “sounded” very concerned, but never called back as she had promised…!!!

  11. Amen!!! It is so true, how it is so easy to spend other peoples’ money, but when it comes to pulling out your own wallet, grab onto something as those brakes get hit hard!!!

    And besides, why should I answer to unknown faces and places in accepting their opinion I should write for something else first?! Maybe I know the patient has failed other meds first, that this lame-o insurance company didn’t have the chart in front of them to confirm it.

    If you agree to this kind of blatant interference, good luck defending that in a court of law. ‘Cause the insurer will NOT be sitting next to you should the plaintiff, you know, your former patient, had a negative outcome by taking the substitute choice YOU as the doctor agreed to when the NON physician told you to. Hiding behind this disgusting rhetoric that “we’re not denying the patient medication, we are just not paying for it” is the most disgusting shell game in town!!!

    Again, I hope there is a wise attorney who is ready to tackle these scum!

  12. Are you telling me that if you knew the price, you would object even though your co-pay was minimal? Really? The problem is not that costs are hidden (they are not, actually) but that you don’t personally feel the pain of the more expensive choice, for as soon as you did, your awareness of the cost changed the doctor’s behavior. There are those who argue that the physician must be responsible for choosing the lower cost options, but can you honestly say that patients will respect a physician who chooses for them based on cost when the cost is of no consequence to the patient? Only the consumer of the service has the power to reduce consumption.

  13. Unfortunately prices for medications are too high and doctors don’t always have a list readily available. I know many doctors prescribe a medication without knowing its actual cost. That’s perfectly ok because their brains need to be focused on medicine and not on prices.

    It would be interesting to learn how much money goes into fixing ailments because patients choose to put aside prescriptions because of prices.

  14. Excellent example of taking the bull by the horns and asking questions to get a med you could afford that was as effective as the expensive one. Hopefully people reading this will better understand how crucial it is that we as patients do our part to tamp down the costs. I found this helpful in shaping my questions:

  15. The only reason those drops were so much is because there was insurance and not a price-consious consumer paying for it. You were fine with your co-pay. Now you are allpay.

    If there was no insurance there would be no 279 dollar eyedrops. Same for everythin that is healthcare.

    Get rid of third party payors and watch the prices melt for lack of demand (at present prices).

  16. somewhere out there, I would hope there is a lawyer who could be creative and find a way to pursue a lawsuit against these prescription plans for interfering with patient care by refusing to allow a patient to access the medication that is medically necessary. Basically what these organizations are doing is preempting the physician’s decision and clinically altering the treatment plan, and that IS a clinical supervisory role, which then makes these organizations culpable for liability should a negatvie event transpire.

    Unfortunately, it means a patient has to endure a negative event to give the lawsuit traction and substance to proceed, and that I do not like.

    By the way, everyone thinks they are the first and most important patient in their doctor’s practice and the doctor remembers all this patient’s medications, so we as physicians can make a snap judgment what to substitute, or even more ridiculous to assume, we will get on the phone and get the matter resolved in 5 minutes. Hey folks, let me let you in on a trivial fact, we get put on hold and transferred to 3 or more extensions just like you when you call. So, if I have 4 patients a day who get delayed in accessing their meds and have to process these calls, and it takes a 1/2 hour or more to resolve, do the math how this adds to my demands in the office. But again, the magical thinking will not be deterred, will it, folks?

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