Lifestyles

Mr. Spock, Mrs. Ashley, and Sugar River Pharmacy

By ARTHUR VIDRO
Last year my breathing medicine skyrocketed in price.

It didn’t skyrocket for everyone. It depends on one’s health insurance. If you’re in a generous plan, great. If not, then like me, you’ll sometimes feel financial pain.

I’m insured through the Affordable Care Act (alias Obamacare). Each year you choose a new plan. It’s up to the consumer to put in the boring time and legwork to figure out one’s needs and determine what each plan covers.

But figuring out what is covered is tricky. For prescriptions, there are various levels of coverage, and sometimes web-site guidance doesn’t put a dollar figure on what your co-payment will be for a given pharmaceutical.

I did my due diligence in late 2017 and carefully chose a plan from Anthem that covered our anticipated needs for 2018 as best I could.

If during the year your needs change, you’re out of luck. My needs didn’t change, but I was out of luck anyway.

For the first several months of the year I was paying $30 as my copay for a month’s supply of Qvar, an oral inhaler manufactured by Teva. There is no generic version available in the United States.

When June rolled around, I learned at the pharmacy that the Qvar I’d been using was no longer available. It’s not that Sugar River Pharmacy had temporarily run out of it and needed to order more; and it’s not that some other pharmacy in town could help me; no, it’s that the manufacturer had stopped making the product.

It was no longer on the market. Teva had replaced it with a purportedly different kind of Qvar — billed as new and improved, naturally.

I looked into it. There was nothing new about the medication itself; the only newness lay in the inhalation mechanism. But that presented a chance for the manufacturer to call it a new product and — for this “new” version — start its patent protection anew.

And possibly to jack up the price.

My insurance plan covered the old Qvar that was no longer on the market, but it did not cover this “new and improved” version, perhaps because this version didn’t exist when I signed up for the 12-month plan. So starting in June, my monthly co-pay for Qvar rose from $30 (for the old version) to $247 (for the “improved” version).

That was the price for people without insurance, and it was the price for people like me who had insurance but whose insurance did not cover the medicine. My health insurance would contribute zero dollars and zero cents toward that $247.

But fear not. Anthem told me if I could get written verification from my prescribing doctor that I needed this drug, then they would grant me coverage for it.

So I jumped through hoops. I got the written information from my doctor, and Sugar River Pharmacy was kind enough to relay the information electronically to Anthem. I quickly received a letter from Anthem saying “We have approved coverage for your request.” But that letter was misleading. I did not have coverage. At best, I had fractional coverage.

For when I ran over to the pharmacy I learned that this coverage meant the insurance company, instead of paying zero dollars and zero cents out of the $247, would now happily pay $15.51 and require me to pay $231.49. That’s right; even with so-called coverage obtained from jumping through hoops, I would now be responsible for 93.7 percent of the full payment.

A far cry from the $30 co-payment I’d forked over the month before.

This is not how health insurance was meant to work.

I don’t blame the pharmacy. They’re as hamstrung by the rules as the patient. Even if the person standing on line behind me can get the very same item for a fraction of the cost, it would still cost me $231.49 per month.

That was out of my budget, so I didn’t pay.

But I had to think. When I think deeply, I summon my inner Spock.

As Spock said in an episode of “Star Trek” (“The Galileo Seven,” for you Trekkers), “There are always alternatives.”

I agree with him. So I thought through the alternatives.

Could the pharmacy somehow come up with the old, non-improved version of Qvar? No, it was off the market.

Could the manufacturer sell it to me direct? After all, there must be a surplus stock of it somewhere.

Nope, not allowed.

I wondered if perhaps I didn’t really need the medicine. So I went without it — and quickly developed ever-progressing bronchitis.

During the summer of bronchial suffering, I thought deeper about alternatives. And then I remembered Mrs. Ashley.

She lived around the block from us when I was growing up — and still lives there, at least 50 years after having moved in. I recalled a cool summer evening in my younger days — either the late 1970s or early 1980s — where my family was on the street having a talk with the Ashleys, who were out for a stroll.

During that conversation, Mrs. Ashley explained about her need for a medicine that was extremely expensive, so much so that she was now buying it, at a much more affordable price, via mail from Canada.

Another alternative! All because of my strong memories of conversations from 35 or more years ago.

I visited my doctor, who prescribed a dose of steroids to remedy the bronchitis, and a prescription for a different inhaler to tide me over until the purchase could be made from Canada.

She tried to dissuade me from buying from Canada, and I understood her reasons. But hey, I’m the patient, it’s my health, and I decided to overrule the doctor’s suggestion. I phoned Canada and set up an account.

Sugar River Pharmacy helped greatly by forwarding to Canada, electronically, my Qvar prescription that was languishing on file. I wonder if all pharmacies would be so accommodating.

How much did I save by ordering from Canada? The Qvar costs me $30 a month — no insurance needed. That’s the same Qvar, manufactured by the same Teva, that’s fetching $247 in the United States.

Makes you wonder — if the drug is sold in other countries at $30, surely the manufacturer is earning a sufficient profit by selling it at that price. Which points out the ridiculousness of the American health care system when it comes to drug pricing.

Oh, and although there is no genetic version of Qvar available to pharmacies in the United States, the genetic version is available through Canada. The batch I got worked fine and cost even less than $30.

The illogic of drug pricing is enough to drive one batty.

I am very grateful for all the help I had. Help from Mr. Spock, Mrs. Ashley, and Sugar River Pharmacy.

If you have consumerism questions, send them to Arthur Vidro care of this newspaper, which publishes his column every weekend.

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