The following anecdote is from a Massachusetts patient covered by Medicare
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.