I am so grateful that my asthma is mild, because I went through this exact same thing not long ago. Via NBC News:
When 22-year-old Cole Schmidtknecht tried to get a refill on the inhaler prescribed by his doctor to prevent asthma attacks, the medication that had formerly cost him less than $70 at his Appleton, Wisconsin pharmacy was now priced at more than $500, according to Cole’s father, Bil Schmidtknecht.
Stunned, Cole left the store with a medication designed to stop asthma attacks once they start, but without the Advair Diskus inhaler he needed to prevent attacks from happening in the first place.
Five days after his pharmacy visit last year, Cole had a severe asthma attack, stopped breathing and collapsed. He never regained consciousness and died. Doctors attributed his death to asthma.
I don’t remember the name of the inhaler I had for those few months last year. I just know it was maybe $10 — until I went to refill it, and suddenly, it was $563. And here’s the crazy part. My doctor told me to find out what they would cover instead, and he would call in the prescription. When I called the pharmacy to ask, the pharmacist emphatically said they were not allowed to give me that information — the doctor had to call himself. (He was a specialist, and pretty busy.)
I may have directed some vulgar language at the pharmacist.
This went on for a couple of days and finally, they told my doctor what else he could prescribe and he sent through a year’s prescription for the new inhaler. At my next visit, I asked what he thought had happened.
He shook his head and said, “A different pharmacy benefit manager paid them off to push a different drug.” I thought, wow. What if I’d had a serious asthma attack while all this was going on?
Now I know.
A part of the insurance system that many Americans don’t know about was responsible for the spike in Cole’s inhaler price. Pharmacy benefit managers, or PBMs, are the middlemen that control behind the scenes which drugs will be on an insurance company’s list of covered medications (called its formulary).
They add or subtract medications through a process that emphasizes profits for the pharmacy benefit manager by way of “rebates” from drug makers, said Gerard Anderson, a professor of health policy and management at the Johns Hopkins University Bloomberg School of Public Health.
PBMs “are looking for the drug that makes them the most money,” Andersen said.
When there are multiple drugs that do essentially the same thing, then there’s a bidding war, usually a silent one.
Oh, and Cole was insured by his job through United Health Group. Of course he was.
