Wednesday, September 26, 2007

The Co$t of Being Depressed

Okay, I've truly lost it. I've just spent the last half hour on the phone calling a couple of pharmacies to find out the cost of antidepressants, all for Shrink Rap. You see, as a doctor, I've never learned what this stuff costs. I know vaguely that the older stuff is cheap, and the latest greatest is expensive, sometimes really expensive. I actually started my research yesterday. I thought I'd compare the prices at a local independent boutique pharmacist in a ritzy neighborhood where home delivery is offered, to a chain, to Walmart or Sams Club with the assumption that Walmart would be the cheapest--though really, I'm not sure of this. My quest was limited, however. By the time I really sat down to do this, it was so late I was limited to 24-hour pharmacies, so no Walmart in the comparison.

With my gratitude to the pharmacists who humored me, here's what I found.

The local independent pharmacy informed me that "our system doesn't allow us to look it up without a prescription." Huh? I asked again several times, they couldn't tell me what a medication cost. Okay....

CVS-- a large chain store-- I got a pleasant sales person on the phone.
Similarly at Walgreens. Pharmacists are generally nice people, I've found.
So all prices are for
30 pills, I aimed at the usual antidepressant doses. A little bit of confusion around Elavil (amitryptiline), one of the older tricyclic antidepressants which I just about never use, but it's cheap. I asked about a 100mg dose and CVS told me it came as 75 mg while Walgreens said they had it as 100mg. I only asked for a few prices at Walgreens, mostly to see if there was variation (there was). Zoloft, Lexapro, and Trazodone are scored pills, so if you take half the listed dose, this will last you two months. Many people, however, are on 200 mg of zoloft, and since the largest pill is the 100mg tablet, double the price for high doses. These are the cash prices, in US dollars, and I called pharmacies in Maryland. I tried to set this up as a table spreadsheet, but blogger ate that format.

Paxil, 20 mg...................... 125.99
generic Paxil 20 mg............ 48.95
generic Prozac, 20 mg ........19.19 .............29.99 (Walgreens)
Zoloft, 100 mg ....................140.99
generic Zoloft, 100mg ......... 45.19
Celexa, 40mg .......................122.99
generic Celexa, 40mg............ 33.69
Cymbalta, 60mg .................. 149.99........... 142.99 (Walgreens)
Nortryptiltine, generic, 75mg.. 31.69
Lexapro, 20 mg ..................... 106.99......... 105.99( Walgreens)
Elavil, 75mg ............................53.59
generic Elavil, 75mg................ 10.99,,,,,,,,,,, 12.39 (walgreens)
Trazodone, 150mg ,,,,,,,,,,,,,,,,,,, 23.19
Wellbutrin XL, 300mg............ 215.99
generic Wellbutrin XL, 300mg... 149.99....... 139.99 (Walgreens)

[from Roy]
Don't forget about Walmart's $4 list. You can buy 30 pills of any of these for $4, whether you have insurance or not. In the hospital, we frequently choose meds for uninsured pts based on this list (eg, Prozac 20 mg = $4/mo. Elavil, Paxil, Trazodone and Doxepin are other choices for antidepressants.)


Anonymous said...

This is really interesting information--thanks for sharing it.

Two things stand out as noteworthy:

a) the very wide variation in prices--two orders of magnitude difference between the least expensive generic $4 Prozac, etc. available at Walmart and the most expensive drugs on the list.

b) the fact that doctors don't have ready access to such information at their fingertips.

In New York, pharmacies are required to provide a list of prescription prices for the most commonly prescribed medicines to consumers on request. Walgreen's website has a tollfree number that New York consumers can call to get this list.

Also, with the help of AARP volunteers who collect price data from pharmacies across the state, the New York attorney general's office has a searchable database showing comparison prices for some of the most commonly prescribed drugs at hundreds of pharmacies across the state. It's a good starting point for New York consumers who want to do comparison shopping to find the least expensive source of their medicine.

The New York Attorney General's initial drug price survey showed a striking amount of price variation for the same drug at different pharmacies, though I imagine that publication of the results has now put some downward pressure on some of the higher priced pharmacies in New York. (In addition, some New Yorker near the border have found it expedient to purchase their medicine in Canada. There are even county government prescription drug plans in Upstate NY which encourage covered employees to purchase their long-term prescription drugs in Canada.)

Along similar lines, there is a proposed regulation in New Jersey which would require all pharmacies to publicly post prices for the 150 most commonly prescribed drugs.

Drugstores routinely publicize and promote their prices for the beauty products and electronic gadgets they sell (without any law requiring them to do this), but apparently it takes some sort of legal compulsion to make pharmacies openly disclose their prescription prices to enable better informed choices by doctors and patients.

--from Dinah's sister-in-law, who's been reading Shrink Rap with interest for a while, but this post brought her out of lurkdom.

Sarebear said...

One worry I have about Walmart's $4 list (a more long-term worry) is that, once they've captured a REALLY large portion of the market, they can and will up their prices, because everyone else will up their prices due to loss of volume (both loss of the discounts they get for ordering volume, and the money they make back on volume by lowering prices, independent of manufacturer volume discounts).

I note that Effexor (and XR) aren't on your list, but that's ok.

I'm on two 150mgs a day. It's $210-$225 for that monthly amount, before insurance. Since there is no generic equivalent, my co-pay is $75 (for non-generics, my co-pay is a certain % or $75, whichever is less). But that $75 may as well be the $200, for all I can't pay either. I'm on another med that's not for depression, that I actually have both xr and non xr forms of, depending on if I oversleep or forget to take in the morning. The XR has no generic equivalent, and is also $75 co-pay for me. This recent addition to my regimen almost doubled my prescription costs. Two other meds that are generic, at the $10 co-pay each.

I think it'll be, what, 2010-20-12 before Effexor XR's patent is off exclusivity, or something? UGH.

When I didn't have insurance, I was getting the Neurontin and Effexor XR directly from the drug companies for free, as we qualified for their programs.

Most of the prescriptions savings plans like Together RX and such, are for people with no insurance, and some drugs (esp. mental health ones) aren't on the list, anyway.

Two sites that pull together a wide range of prescription-assistance programs (most are for non-insured, but some will help w/copays and more if you have an illness in their specific, limited list):

Something's GOT to change, here, because this situation is just STUPID.

Sarebear said...

Oh, and Target has a $4 list too (generics, of course.)

The Shrink said...

Our British National Formulary lists drug costs. They vary since there can be (significant) discounts for hospitals ordering quantities from drug companies. Some prices are for 28 day packs so I've converted these to 30, so we're comparing like with like.

To compare the same list for interest (and converting to US dollars at today's exchange rate) UK drug costs next to your listed drug costs are :

Paxil 20mg : $26.69 ($125.99 in the US)
generic paxil 20mg (paroxetine) : $14.47 ($48.95 in the US)
generic prozac 20mg (fluoxetine) : $2.99 ($19.19 or $29.99 in the US)
Zoloft 100mg : $63.12 ($140.99 in the US)
generic zoloft 100mg (sertraline) : $4.43 ($45.19 in the US)
Celexa 40mg : $54.56 ($122.99 in the US)
generic celexa 40mg (citalopram) : $9.23 ($33.69 in the US)
Cymbalta 60mg : $60.01 ($144.99 or $142.99 in the US)
Nortriptyline 75mg : $43.64 ($31.69 in the US as you get it generic we get it branded)
Lexapro 20mg : $54.56 ($106.99 or 105.99 in the US)
Elavil 75mg : isn't marketed in the UK
generic elavil 75mg (amitriptyline) : $7.40 ($10.99 or $12.39 in the US)
Trazodone 150mg : $49.75 ($23.19 in the US, no idea why we're so expensive!)
Wellbutrin XL 300mg : $80.52 ($215.99 in the US)
generic wellbutrin XL 300mg (bupropion) : isn't marketed in the UK

Quite a proce differential for most products, especially branded rather than generic drugs.

The Silent Voices in my Mind said...

The anti-depressants can wipe you out. Try adding a few anti-psychotics like Seroquel and Invega. I have 7 (SEVEN!) psych meds for me alone. Then try to cover 2 other people with 3-5 psych prescriptions each and 2 others on other maintenance meds for other things with an insurance that has just enough coverage to keep us off the Drug companies help programs. And we can't get government medical assistance because my SSDI puts our income $20 per month over the limit and doesn't account for medical costs at all.

My psychiatrist gets so frustrated with me for going on and off my meds but I have to cover my kids first, then hubby since he has to function at work and then I get as many of mine as possible. We've tried the less expensive options and they haven't worked - "treatment resistent" he calls me.

Psychiatrists: I know you get frustrated with patients who aren't compliant with their meds, not taking as much as they should or not taking them at all. It obviously isn't always the case, but try not to get too angry with us, even if it causes us to completely fall apart. Sometimes we don't have a choice and are just as frustrated as you are. My psychiatrist is forever scolding me for non-compliance but he doesn't give me a chance to explain why and the one time I mentioned it, he said I needed to "just find a way; it's not like [I] have another option".

How wrong is it when a mental health hospital stay is less expensive than one month of maintenance meds for me?

Alison Cummins said...

Before Quebec brought in its universal provincial drug insurance I couldn't afford the $75/month (this was about ten years ago) for antidepressant meds. (Even since before public drug insurance, Quebec has a deal with the pharmaceutical companies whereby the hospitals will purchase drugs for them on condition that the drugs are sold at certain standard prices to the pharmacies. So we don't get the variation you do, and we aren't required to shop around.)

Under the universal drug insurance program I could get all the drugs I needed with a co-pay of $25/month. Total. For all the drugs together.

I only needed provincial insurance for about ten months because after that I was employed by an employer who had a private insurance plan, and I switched (as required by law). I don't have a co-pay at all any more.

Yeah, the Canadian medical system sucks, don't it.

Anonymous said...

Ah, let me add a couple to your list:

Effexor XR, 150mg, 60 count: $226.13


Effexor XR, 75mg, 30 count: $104.34


Lamictal, 100mg, 60 count: $250.11

Add those above to the Wellbutrin XL and I'm swallowing over $930 in pharmaceuticals and I know I'm far from the worst case scenario. (I don't even want to imagine what Silent Voices' costs are.)

Anonymous said...

I just don't understand how the wholesale price of medications is so high in the US. Well I sort of do (to do with government negotiations on price so that medications will be subsidised) but it's just a joke.

I don't have a wholesaler price list to hand, but of the medications on your list, the following ones have wholesale costs under $30 (Australian $... so less than that in your dollars). Note that these aren't costs to consumer, however these medications are all subsidised by the government so patients would not pay much more than $30 for any of them.

Zoloft 100mg and 50mg
Aropax 20mg (ie. Paxil)
Cipramil 20mg (ie. Celexa)
Nortriptyline - any strength - wholesale cost less than $10.
Lexapro 10mg and 20mg
Amitriptyline - also very cheap

Cymbalta is not available here yet, and we only have bupropion as a limited access item for smoking cessation at present. And trazadone doesn't appear to be listed anymore...

I know off the top of my head that wholesale prices for Efexor XR are under $30 for the 37.5mg, about $35-40 for the 75mg and $50 for the 150mg.

What makes me mad is that many of these drugs are manufactured in the same factories for you guys and for us. It's a disgrace that the prices vary by so much. Even if someone is not covered by Medicare (eg. a visiting American!), buying their medicine as a "private script" will still be a lot cheaper here in most cases. Lots of rage!

The flexibility in what is charged by the drug companies was demonstrated a couple of years ago when Ritalin was first listed on the subsidised list. Prior to its listing, the wholesale cost was about $45 for a pack of 100 standard release tablets. Once it was listed, the wholesale price dropped to $9. Same thing happened with Concerta this year - used to be $177 wholesale for the 54mg, now $77.

Rach said...

On the same note as Alison Cummins - my plan only covers 80% of the meds (not including the dispensing fee). Plus, it doesn't cover the $100 a month I spend on the naturopathic stuff that I take in addition to my meds - they do help, you know!

With the Canadian dollar being at par with the US$, I almost wonder if it's worthwhile seeing if I can get my meds filled in the states. I'm sure it's unethical, and probably illegal. But hot-damn, if it's cheaper... that's probably worth something to my already fragile sanity.

Anonymous said...

well Rach, fisrt your doc would have to be able to write a prescription and most CDN docs aren't licensed to do so. Or you could go to the States to see a doc but the cost of gas or airfare would rule that out plus the visit to the doc would cost big bucks. don't buy online since you will get rat poison or something similar.they just had an article about how easy it is to bypass customs and import drugs but the researchers are still trying to determine what the heck they actually got. also, from experience most drugs are cheaper here irrespective of the exchange rate. one little way to save is to avoid the shoppers drug mart chain that is eating up every small corner drugstore.
we pay 1 thousand per month for meds for two people.

Anonymous said...

Yikes, I just checked on the prices of my meds. I knew they were expensive (over $1225/mos!), but I haven't checked on them in a while.

My only psych med:

Lamictal, 30 tablets of 25mg: $150 (I'm debating on whether to titrate back up to full strenth at $270/mos or switch to Lithium, that's why the dose is so low right now)

Switching to Lithium:

Lithium Carbonate ER, 60 tablets of 450mg: $32

Wow, what a cost savings!

Anonymous said...

silent voices: you put it so well. i'm glad you left that comment, as yours is a common situation. i am on 5 different psych meds myself right now and just wouldn't be able to afford meds AT ALL if it weren't for various locally-run programs that help me out from one month to the next.
it's a really shitty situation when docs are writing that you're not "med compliant" in your chart when they're putting you on meds that you can't afford to purchase!
that's part of the reason why i was surprised that so many psychiatrists have NO IDEA how much the meds they are prescribing cost their patients out in the "real world" (beyond the realm of the couch).

Anonymous said...

p.s. hey docs... for an even closer estimate of "the cost of being depressed", don't forget to add in your salaries as well :P

Anonymous said...

I've been reading a lot of interesting articles on the Last Psychiatrist's blog about the futility of polypharmacy (ie: treating with 2 antipsychotics or a mood stabilizer+antipsychotic)in many cases. What do you shrinks think? Seems like there are a number of people here on an extreme number of medications.

Anonymous said...

forget about cutting and pasting links. you have an ad up for which advertises some "natural antidepressant". who knows what it really is and if people will be duped because they saw it on your site and figure you endorse it. since you can't really control what you are advertising this is uncomfortable territory and for how much gain? if you need the money make your site subscription based if you want but the ads really suck.

Mary said...

As A psychiatric social worker I am constantly amazed at the psychiatrists' seemingly willful ignorance of the price of psych meds and unwilligness to prescribe less costly alternatives. It doesn't matterf that the atypical antipsychotic has milder side effects if it costs twice the patient's monthly salary. And all of our clients lie in grinding poverty. The richest survive on a luxurious $900/month. Too much to qualify for subsidized housing unless they are elderly. Typical one bedroom apartments are $600/month. Zyprexa is $800?month. You do the math. This patient needs haldol, even if it is older.

Anonymous said...

My first pdoc, who prescribed my Lamictal, knew exactly what it cost (she told me in her office). At that point I still had in good insurance, so an expense drug was not a problem. Later on when my coverage switched and my benefits ran out, she made sure I always had enough free samples so that I could stay on it. I didn't qualify for the PPA programs, so this was the next best thing.

JC Jones MA RN said...

Great post. Great discussion!

DrivingMissMolly said...

I've been on everything.

You forgot to mention the "augmenting" or "wishful thinking" drugs.
I've been on Provigil and Adderall and also paid a fortune for a trial of Cymbalta which didn't work.

I loved the Effexor because it got rid of my cravings for sweets, including chocolate, but the projectile vomiting and blurred vision made Effexor a "don't" for me.

Currently I take lithium, paroxetine, alprazolam and clonazepam. Luckily I have insurance so I pay a cheap co-pay, but I'm curious how much they'd be without insurance. I'll have to check.

I'm glad I didn't have children because I couldn't afford them! That, and no way was I willing to pass on my bum depression gene. I wouldn't wish it on my worst enemy, let alone a beloved child.


Anonymous said...

When I was uninsured and taking 40mg/day of generic Prozac the weirdest thing to me was that it was cheaper -- often much so -- to get 60 20mg pills for the month than 30 40mg pills.

Also prices at Costco were much cheaper than anywhere else, but I had to drive 1 hr (roundtrip) once a month to get there.

Also, you can get a lot of this information online, at least for the large chain pharmacies.

R. May said...

I know this is late but here's another tidbit for you.

I have insurance. With insurance a 30 day supply 20 mg of lexapro is 35.00.

But my dosage is 30 mg. And because the insurance company knows better then my doctor what the correct dosage is, my cost per month is $85.00.