Getting the Best Deal on Prescriptions Is Too Complicated Even for Me

I have mild persistent asthma, which means I take a daily suppressive inhaler and occasionally also need to use a rescue inhaler. I moved a year ago to a new job, but I had enough medication stockpiled that only a few months ago did I finally need to get more inhalers. You would think that, as an internal medicine physician and also a health policy researcher, I have the rare perfect skill set that would allow me to get the best deal on these medications. But you would be wrong.

I have a high-deductible health plan and haven’t made any claims this year, so I was confident that I would be paying the full price for my medicine since that’s what it says in my benefits description. And since inhalers can be expensive, I decided I should start by logging into my health insurance profile to see if they have a formulary that would list which inhalers are the cheapest.

I didn’t find a formulary. But I did find a very interesting tool that I guess is supposed to be better. It’s called “Rx Savings Solutions.” It lets me look up a medication and then shows me prices. Simple, right?

So I looked up fluticasone proprionate–not to be confused with the nasal version fluticasone proprionate, or the other fluticasone proprionates that are combined with other medicines, and good thing I know that HFA means it’s an inhaler. It said the estimated cost was $192 for a 1-month supply, but that was for a retail pharmacy. I could instead use a mail pharmacy and pay $562 for a 3-month supply (I initially didn’t notice that price was for 3 months instead of 1).

But it went further than that. It offered alternative formulations of the same medication (inhaler vs diskus, although the diskus was listed as the same price as the inhaler), and it even offered alternative medications (fluticasone furoate, beclomethasone, budesonide, . . .). I guess if you are using that tool real-time while at the doctor, that could be helpful in steering them to an equivalent but cheaper medication. But it would probably be a frustrating time-waster for the doctor!

Luckily, I was writing the prescription myself. And since I knew that any of those other medications would work fine, I felt confident. I was even savvy enough to look at the recommended dosing frequency and the number of doses per inhaler to make sure they would each last the same number of days. Yes, I was confident at this point.

Beclomethasone and mometasone were both within $1 per month of the price of fluticasone, so I just decided to go with fluticasone because that’s what I’ve been using. I selected it, which then took me to a page listing the actual prices at a variety of pharmacies. In this case, every pharmacy listed had the same price, still that $192 for one inhaler. Other medications I have searched have showed different prices depending on the pharmacy. I’ve heard of various pharmacy-specific discounts, so I wasn’t sure if I should trust the prices listed, but I wasn’t willing to call each pharmacy to ask.

But $192 seemed like a lot of money per month. Remember, I’m a young doctor paying off large debts, and also remember that I grew up in Canada where medications are cheap. So I decided to broaden my search.

I checked GoodRx. They claim they have prices that will beat my insurance plan’s prices! I’m sure they do, but in this case, the price for one fluticasone inhaler was $256 at all the pharmacies listed, so no luck there. I didn’t go out of my way to check the GoodRx prices for beclomethasone and the others, although I should have if I wanted to truly be confident I was getting the best price.

I’ve heard of Canada mail pharmacies, so then I looked into those. There are a few options, so I started checking prices on all of them for a few of my medication options and their various formulations. This took some time, and eventually I was able to find one that offered the exact same fluticasone inhaler for $35. This was a killer deal! Except there are uncertainties about if ordering meds from my motherland will get me in trouble.

Ultimately, I had run out of fluticasone and my asthma was starting to get bad, so I gave up my search for the best price and just went with what I knew I could get the next day. I called in a prescription for a fluticasone inhaler to our local Walmart. When my wife picked it up for me, she said they only charged her a $36 copay! But they had to switch it to the diskus version.

I don’t know why they didn’t charge us the full price. But I think I know why the switched it to the diskus version. Looking again at the Rx Savings Solutions website, it turns out the price listed there is $182 for the diskus (as opposed to $192 for the inhaler), but I only see that price when I search the diskus directly. If I search for the inhaler and then look at the price of the diskus in the alternative formulations section, it lists the price of the diskus as $192. Go figure.

In a way, it’s good that the cheapest price is the one any normal consumer of healthcare would have gotten. Unfortunately, that’s probably not normally the case. But any other person on my same insurance plan who needed a refill for fluticasone would have gone to their doctor and asked for a refill, then the doctor would have electronically sent a new fluticasone prescription to their usual pharmacy (having no idea whether it is the cheapest option for that patient’s insurance), and then the patient would have picked it up and paid whatever price the pharmacy requested.

Do you want to know how doctors figure out how much a medication will cost a patient? Well, the real answer is that we don’t figure it out. But for those times when a patient is requesting a price due to severe financial constraints, we call the patient’s pharmacy and have them run a test prescription. The computer then spits out how much the patient’s out-of-pocket cost will be. That’s the only way to know the actual out-of-pocket cost. Not even a pharmacist can tell you that information without running a test prescription. Can you imagine a physician really trying hard to find the best deal for a patient? They would have to call multiple pharmacies and have them run a variety of test prescriptions. That is completely impractical.

This is yet another manifestation of the despicable complexity in our healthcare system, and it wastes so much time and money of patients, doctors, and pharmacists.

Did you notice the impossible number of variables someone has to sift through to find the cheapest price for a single treatment? The insurance plan, the number of months’ worth of medication you’re buying, the outside rebate programs, the mail options (U.S. and international), the alternative equivalent treatment options, the alternative formulations for the same meds, the frequency of dosing, the search term used to find the price of a medication, and the pharmacy-specific price impacts.

There are clearly other variables I still don’t know about, which is why, even after all of that, I still didn’t know what my actual out-of-pocket cost would be.