This is the first article in a series on the cost of medications.
While it’s not news that some pharmaceuticals are exorbitantly expensive and therefore unavailable to our patients, I have learned that there are ways around the obstacle of cost for at least some medications. I want to tell you what I’ve learned about the high cost of two medications: aripiprazole, the generic of Abilify, and modafinil, the generic of Provigil, but the lessons learned may apply to other psychotropics – and Smokey Robinson and the Miracles said it best in a line from their 1960 hit song, “You’d better shop around.”
Three years ago, I wrote an article in this column called “The surprisingly high cost of Abilify.” I received calls and emails from psychiatrists across the country, most of whom told me that everyone knows to get Abilify from Canadian pharmacies. Everyone but me, apparently, but now I know, too. Another option I came up with for patients on low-dose Abilify is to have them purchase 3 tablets of the 30-mg strength at a compounding pharmacy and have them reconfigured into 30 tablets of 3 mg each. I learned that this was allowed as long as the medication was not being compounded to a dose that the pharmaceutical company makes.
Over the past few years, the price of aripiprazole has come down considerably, or so I believed. A patient recently complained that his copay after insurance for a 1-month supply of 2-mg tablets was hundreds of dollars, and she showed me a bill where the cost before insurance was more than $2,000! Another patient, also someone with commercial insurance, said he couldn’t afford aripiprazole and asked me to phone in a prescription to healthwarehouse.com . The medication was mailed to him for about $35 a month. Finally, a third patient with Medicare used an online service called Blink Health . He explained that he paid for the medicine online with a credit card – about $80, far less than the price quoted by the pharmacy. He was then given some type of code to present to the pharmacist, who then supplied the medications. In this case, the same pills, the same pharmacy, at a fraction of the cost. With that, I called several pharmacies and asked about the price of generic Abilify, 5 mg, 30 tablets.
I also wrote a column about the tremendous difficulty I had trying to get preauthorization for modafinil, in “Preauthorization of medications: Who oversees the placement of the hoops?” In that case, I spent weeks trying to get approval for the medication, and in the end, it was not approved, and the patient was not able to get it. Soon after, I learned on a Psychiatry Network Facebook discussion that generic Provigil is not expensive at all! Once again, I fired up my phone and called around. Those prices and those I found for Abilify are listed in the chart.
Obviously, these cost differentials are staggering; the same medication costs more than 45 times more, depending on the pharmacy. Why is this? It seems hard to point this finger at Big Pharma; the price difference is somewhere down the line. So far, I’ve been told that it’s like procedures that have vastly different prices at different hospitals, or the pharmacy’s markup. I have yet to meet anyone who shares my outrage, or who can adequately explain this phenomena.
So these are cash prices; they do not take into account the cost with insurance. My patients have educated me after they could not afford the insurance copays. I wondered about my own coverage, and signed on to my pharmacy benefits manager account to look up the cost of both Abilify and Provigil. I’m sorry to say that I can’t report back: With my health insurance, Empire Blue Cross and Express Scripts, both medications require Coverage Review. It was also noted that Abilify requires Step treatment; I must first fail other medications. Should I ever need either of these medications, you’ll know where to find me: in line at the Costco pharmacy. I’ll be the one dancing to Smokey Robinson and the Miracles . https://www.youtube.com/watch?v=AQGXa3FiXKM
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
