How do insurance and pharmaceutical companies decide what to charge for prescription drugs?
How do insurance companies and pharmaceutical companies make the decisions they make? How do they decide which medicines to provide and what to charge for them? How do insurance companies decide what drugs are in their formularies? How do they determine the copay that the patient will be charged? How do you as a consumer determine what your medicine would cost you if you were speaking with your insurance or a pharmacy regarding a prescription you have?
It is our belief that the insurance companies and the pharmaceutical companies that make drugs are in bed with each other to maximize the profit they can make from all of the drugs they make. Your local pharmacy does not really have anything they can do to impact these decisions. Your doctor writes the prescription they believe would help your health condition and gives it to you. You take it to the pharmacy that you use (although our insurance companies are encouraging us more and more to try to use mail order pharmacies to receive three month doses of our prescriptions and to wean us away from our local pharmacy.) The pharmacy (local) will look at your insurance card and contact your insurance company. That company will look at the formulary they have (a list of all the drugs they have to send out and what each of them costs.) The insurance company will tell the pharmacy how much to charge and how much your individual co-pay will be. There is nothing you can do about that except look for a new insurance company or look into the various policies your company offers which usually you can change once a year during open enrollment for the company you work for. If you work for a large company they may have a Human Relations department that can work with you and the insurance company your job has a relationship and a contract with. At the end of the day, you must pay whatever the drug company decides to charge for your medicine and the co-pay that your insurance company requires for your coverage as determined by the contract with your employer.
Many Americans are experiencing sticker shock when they go to obtain a prescription each month because the pharmaceutical companies that make the drugs have decided not to make as many of that particular drug and now there is an artificial scarcity and the prices are higher. Sometimes the pharmaceutical companies just arbitrarily and unilaterally decided to raise the prices they charge for medicines just because they can.
I have an app for doctors called Epocrates that supplies the cash rate for all drugs, and I am horrified at the cost.
Here are some examples as of Oct 2017
ADD, ADHD one month of medication cost
- Focalin/Dextromethylphenidate – $800
- Modafinil – $800
- Metadate CD – $369.99
- Vyvanse – $253.30 – $332.99
- Strattera – $398.93 – $571.99
- Dexedrine ER – $688.14 – $1,399.49
- Dextroamphetamine ER generic – $245 – $456.86
- Concerta – $335.99 – $417.65
Testosterone Preparations per month
- Testim gel – $608.24
- Androgel – $526 – $627
- Axiron gel – $760
- Striant buccal tablet – $644
- Fortesa – $570
Diabetic Drugs and Injectables per month
- Byetta 3 pens – $1,984
- Victoza 3 pens – $1,400
- Trulicity pens – $658 – $730
Diet Drugs per month – These are usually not covered by insurance
- Adipex P 30 – $86.19
- Suprenza – $229.93
- Belviq – $270
- Benzphetamine – $132
- Contrave – $255
- Phendimetrazine – $39.99 (105mg)
- Qsymia – $109 – $274
It is our hope that by having this discussion we can encourage you to contact your government representatives and politicians to complain about this process and ask that something be done to increase regulations in this area that will protect the consumer and regulate the cost of medicines in a more realistic and affordable way. We cannot continue to let the driving force of all our prescription medicines be the goal of absolute profit by the pharmaceutical and insurance industries. The way we can impact that is through concerted political action. Please get on board.
This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author, with Brett Newcomb, MA., LPC., Family Counselor, Presenter and Author. www.BioBalanceHealth.com.