Rx Central Oregon: Drug prices can be a complex puzzle

There are a lot of factors in the price of a pill. Think of it like the stock market: Numbers are going up and down, changing constantly with internal and external forces.

” It is complex, how many fingers are in the pie and how much goes into the prescription process,” said Kristen Erickson, the owner of Westside Pharmacy.

There are a number of factors that go into what comes out of your pocket when you pick up a prescription. One is your copay.

“Patients’ copays will be different at different pharmacies if one is a preferred pharmacy with their insurance plan,” Erickson said.

Kyle Rayl lives in Bend and is a Type 1 diabetic.

“It’s always something that’s in front of my mind,” Rayl said. “Something I’ve got to be thinking about.”

He was diagnosed 19 years ago this April, and now wears an insulin pump and a continuous glucose monitor. He’s dependent on insulin to stay alive.

“If I don’t have insulin for more than an hour, it can become a catastrophic event,” Rayl said.

He’s made the trip to the emergency room for medication because his insurance would not pay for a refill.

“I’ve ran out several times, and sometimes it’s due to the insurance itself trying to tell me, ‘Well, your prescription isn’t ready to renew yet.’ But it’s like — OK, I get that, but my insulin needs change sometimes, and sometimes I’ll run out quicker than others,” Rayl said.

Rayl has been on his parents’ health insurance in California, but that ends next summer when he turns 26.

In the meantime, he’s covered, but has no access to affordable health care in Oregon.

“So whenever I need prescriptions or medical care appointments I actually have to drive down to Sacramento,” Rayl said.

Right now, he pays about $90 a month for insulin from preferred pharmacies in California. That’s not including test strips and other medical supplies, which can cost anywhere from $50 to $300 a month.

Westside Pharmacy owner Kristen Erickson said most insurance plans in Bend have the same preferred pharmacies, but that doesn’t mean you’ll be paying the same price at each preferred location.

“There are so many factors in the pricing,” Erickson said. “We buy from the same wholesalers that Safeway does. Even still, our prices are going to be slightly different because our contracts with the wholesalers are slightly different.”

Part of this comes down to which “cash price” the pharmacy chooses — and that varies drug to drug.

“You’ll see prices fluctuate on a sometimes daily basis, and different generics — the same generic drug might be $20 from one manufacturer and $200 from another manufacturer, but both of those are for sale at my wholesaler,” Erickson said.

And it doesn’t end there.

“The insurance company and pharmacy benefit manager tell us the value of the drug, and tell us how much we’re going to get paid, regardless if our price is higher than that,” Erickson said.

And sometimes, it’s not just you that’s biting the bullet with a payment.

“So every day, we fill prescriptions at a loss, because they say, ‘You’re going to get paid 40 bucks and that’s it,’ even if we had to buy it for more than that,” Erickson said.

There are times where you could get a generic medication for less money, but again, your insurance company makes that decision for you.

“There are times when your insurance plan has an agreement with a brand, and they require you to use that brand,” Erickson said. “We see that on a daily basis… where we are going to run the generic, they’re going to kick back a rejection and say, ‘Use brand.'”

When it comes to the ability to pay for medication, Erickson said she sees the whole spectrum. “So for some people, if I say, ‘Your copay is $20,’ they’re like ‘I’m going to have to wait, I’m going to have to come back.’ And other people I say, ‘Your copay is $120’ and they’re like, ‘No sweat.'”

Top prescriptions filled vary state by state. Here in Oregon, three medications stand out from the rest. The first treats high blood pressure, the second heartburn and stomach ulcers and the third is for neurological conditions, according to medicaid.gov.

But here in Central Oregon, there’s a variation.

Westside Pharmacy employees say the three most common types of drug filled at their pharmacy are: blood pressure, antidepressants and antibiotics. Thyroid medications come in fourth.

Some insurance companies even offer incentives for you to switch to mail-order. With this comes convenience, but there are downsides to consider.

“The thing that we find a lot is that it gets delayed, it gets lost, it’s not there,” Erickson said. ” We have people all the time coming in saying, ‘I need a week of my medication because it’s not here yet.'”

When deciding on your “home pharmacy,” no one knows what your payment will be until they file a claim with your insurance company.

When it comes to discounts, manufacturers’ coupons directly from the drugmaker are the things to look for. For everything else, beware.

“Those companies are basically taking away a margin for the pharmacy, charging the pharmacy a fee and selling your information,” Erickson said. And because of this, many pharmacies are not accepting these types of coupons any more.”

One such company, GoodRX, reached out to NewsChannel 21 and a representative said they do not sell information. However, she could not speak for other similar companies.

She also shared a link to information provided to customers regarding how GoodRx does and does not use personal information: https://support.goodrx.com/hc/en-us/articles/115004989663-How-does-GoodRx-use-my-personal-information-.

Rayl said he does not use any coupons or programs to lower his premiums and copays. But as an active young man with a delicate condition, he’s looking toward the future with caution.

“You know, you hear these stories of people just recently that are around my age that have died because they were two days away from a paycheck and they couldn’t afford to go buy insulin because it’s hundreds and thousands of dollars to be able to do so,” Rayl said.

For now, Rayl’s focus is finding the right insurance that will keep his costs low and cover the life-saving prescriptions he needs.

There are 10 days left to choose a plan through open enrollment for 2019 health insurance coverage. Erickson said she has an app that can help you choose a cost-effective plan based on which medications you take.

On a related note: In the midst of an opioid epidemic, there’s a level of responsibility pharmacies carry when it comes to prescribing the potentially addictive painkillers.

NewsChannel 21 asked Kristen Erickson what role her business plays in it. We’re told the employees strictly follow the rules — like the number of days allowed between fills.

Westside also checks a database called the Oregon Prescription Drug Monitoring Program, or PDMP. It includes information on where a patient has been filling, and how many doctors they’re seeing. That way the pharmacy can try to intervene if necessary — which Erickson said is out of caring for the patient’s well-being, but can be difficult.

“To talk about the risk of addiction upfront pretty comfortably,” Erickson said. “It’s a little trickier to address possibly seeing someone who has an issue and finding out if they want some more help.”

A positive trend Erickson’s seeing in Oregon — awareness. She said more people are choosing not to fill controlled medications until they know they need it.