Jill Schramm/MDN Medicines play a significant role in health care, but prescription prices can vary dramatically.

A 30-day supply of a generic cholesterol prescription could cost a person as little as $35 or as much as $282 in Minot.

Price disparities among pharmacies reflect the individual circumstances of the retailer but, especially in large price differences, disparities result from what wholesalers charge and whether volume discounts apply. Even timing of wholesale purchases can make a difference as prices can go up or down for a particular drug over time, according to the North Dakota Pharmacists Association.

In the case of Crestor, competing rosuvastatin calcium generics have been on the market only since last April. A variety of purchasing factors were likely at play in a check of six Minot pharmacies in January.

Other drugs also can have big price differences. Prices for Metformin, a diabetes medicine, ranged from $4 to $27.23 at different Minot pharmacies last month. Losartan, used to treat high blood pressure, ranged in price from $14.95 to $62.95. Generic Synthroid, a thyroid medication, ranged from $16.49 to double that amount at $33.

Variability in prices is largely a concern of self-pay patients, though. Those patients make up a small share of the prescription market. The Kaiser Family Foundation lists North Dakota’s uninsured rate at 8 percent in 2015.

Mike Schwab, executive vice president for the pharmacists association, estimated that percentage may have declined due to Medicaid Expansion and increased coverage under the Affordable Care Act.

North Dakotans whose drugs are covered by their health insurers generally see consistent prices for the same prescription among pharmacies. Insurers operate under a formulary price developed with drug suppliers, which along with co-pay requirements, determines what their subscribers pay.

Insured patients have help with their drug costs but sometimes have less flexibility. For instance, they may be required to use a mail order pharmacy.

“That takes away patient choice, and that’s something the state association is looking at,” said Carolyn Bodell of Minot, a Trinity Health pharmacist and a member of the pharmacists association board.

Bodell also said insurers might require specific medicines to be prescribed in some cases, or at least require the patient to try a certain medicine first or get pre-authorization. Typically, this is due to price arrangements with the manufacturer.

Generics are a good way to save money, but again, savings can depend on the insurer, Schwab said. He said pharmacy benefit managers – a middle man in the pharmacy business – have clouded the transparency of drug prices and played a role in which drugs are covered by insurance. Sometimes those covered drugs aren’t the generics. There have been cases in which manufacturers provide rebates to pharmacy benefit managers on brand name drugs to keep generics off the formulary.

Schwab and Bodell recommend people prescribed a brand-name product go to the manufacturer’s website to look for a co-pay assistance card. A variety of websites offer drug coupons, but the manufacturer cards are the most reliable in terms of being accepted by any pharmacy, Bodell said. Federal law prohibits Medicare, TRICARE and Medicaid patients from using these programs, but sometimes manufacturers will have other offers they can utilize, she said.

The North Dakota Senate has taken testimony on Senate Bill 2258, which changes rules related to the interaction between pharmacy benefit managers and pharmacies. It includes the following provisions affecting consumers:

– A pharmacy benefits manager or third-party payer may not charge a patient a co-payment that exceeds the cost of the medication.

– A pharmacy or pharmacist may provide relevant information to a patient, such as the cost and clinical efficacy of a more affordable alternative drug if one is available. Gag orders placed on a pharmacy or pharmacist are prohibited.

Schwab said pharmacists can be barred by gag orders from telling patients that they are being overcharged. Lawsuits exist in other states over the practice of clawbacks, in which pharmacy benefit managers or insurers set artificially inflated prices that result in patients paying more than the drug’s listed cost, with the pharmacy benefit manager or insurer reaping the profit.

When it comes to insurance, not all pharmacies take all plans, either. Pharmacies must sign on to the plans to participate and there are some that do not reimburse enough to make participation worthwhile, Bodell said. This is mostly an issue with Medicare Part D, where a wide variety of plans exist. When seniors sign up for Part D insurance, they need to check each year to ensure their drugs are covered by the pharmacy of their choice because formularies do change, she said.

“It’s good to go to one pharmacy to get all their medications so records can be checked for interactions. They know their history,” Bodell said.

Another potential option for saving money on prescriptions in North Dakota is the state repository program, accessible through a link at nodakpharmacy.com. Pharmacies that have drugs that are near their expiration, unclaimed prescriptions or shipment errors can make these drugs available through the repository to patients for free, or for dispensing fees that can be as little as $4.

Although there is no guarantee of drug availability, pharmacies or physician’s offices often can help in accessing medicines if available on the repository. Medicines available elsewhere in the state can be made accessible via a transfer to a local pharmacy.