ó Charles Conn stopped in to see his pharmacist to
fill a prescription for a cough that had persisted for a
month. Once he saw how much the medication cost, he
could have used a side order of blood pressure pills.
price, under his insurance plan, was $91 for 30
nonnarcotic Benzonatate gel caps.
told him, ĎIím not paying it,í" the Baldwin
dollars isnít the most expensive prescription
medication sold in a pharmacy, but for a retiree on a
fixed income, itís not a payout to be taken lightly.
the pharmacist had flagged the prescription and was able
to sell the medication for $26.10 in cash.
66, happily paid the lower price but the episode left
him wondering: Why would a prescription cost nearly four
times more through his insurance plan than paying cash?
answer may lie in the vagaries of pharmaceutical
pricing, which include the wholesale prices that hardly
anyone pays and the largely unseen influence of
third-party pharmacy benefit managers.
Connís case, there was an immediate hurdle he didnít
recognize at first: Medicare Part D, the prescription
drug coverage for seniors, does not cover cough
suppressants and Benzonatate was not in his planís
formulary of covered medicines. That meant he could not
take advantage of any discount negotiated by his
insurer, UPMC for Life.
still didnít explain why the gel caps cost much more
through his insurance.
Tritinger, a pharmacist at Connís pharmacy, said it
probably has to do with a price set by the wholesaler
that is rarely charged to the patient.
canít even tell you what goes into setting that
price," he said, adding that usually, the
pharmacist "would have managed that down" to a
lower price or, absent that, charged a lower price
most pharmacists, the price is a courtesy. There is some
compassion," he said.
advice: Check ahead to see if a new medication is
covered under your insurance; ask to speak to a
pharmacist if the price seems high; and, if practical,
shop around if youíre unhappy with a pharmacyís
for Life literature also suggests checking with its
staff to see if a similar drug is covered under its plan
when the prescribed drug is not in its formulary.
insurerís members can request the plan to cover a drug
not in its formulary "at a pre-determined
cost-sharing level," although such exceptions
generally are not granted unless alternative medications
would not be as effective or could cause adverse side
Eppel, executive director of the Pennsylvania
Pharmacists Association in Harrisburg, said a pharmacy
benefit manager ó typically a third party that manages
prescription benefits for an insurer ó also may be
telling a pharmacy what to charge for a medication.
one sees exactly how much the (Medicare) Part D plan is
billing the government," she said."A lot of
pharmacists believe that the government is paying far
more than they need to."
back, Connís wife, Christine, said they are is still
"flabbergasted" by the price difference and
now wonder if they should ask for the cash price every
said thatís probably not necessary. "Ninety-nine
percent of the time theyíre going to get a better
price through the insurance company."