The pharmacist’s voice, when she calls to say my prescription is ready, is slightly concerned.



“You may want to check with your insurance company,” she suggests, noting that the price has gone up “by a considerable amount”.

Indeed it has. Until 1 October, I paid my pharmacy $25.78 for a monthly supply of generic Fioricet with codeine, the medication I take to deal with breakthrough migraine headaches – the stuff my so-so preventative drug, Topamax, doesn’t stop in its tracks.

Now, under the terms of my insurance with Blue Cross Blue Shield of Rhode Island, it will cost me $85.54. That’s a 232% price increase for the generic version of a drug that has been on the market for about 90 years.

This is just one more example of the impact opaque pricing has on our healthcare costs.

Overall, Americans spend significantly more for prescription medications than do citizens of any other developed nation. We do so directly, through higher prescription costs, and indirectly, as high drug costs drive up our insurance premiums and our taxes, via higher Medicaid and Medicare costs.

I should be accustomed to the high price I must pay in order to live with the chronic, severe migraine headaches that first struck me 37 years ago. It took my mother only seconds to realize I had become the fourth generation in our family to be afflicted with migraines, when I struggled home from an afternoon babysitting job, unable to see or communicate clearly, in agony from the pain on the right side of my head. The neurologists confirmed her diagnosis.

Most of the medications those doctors prescribed proved relatively ineffective or had intolerable side effects. The triptans, wonder drugs to treat migraines that have been a boon for many, drove my blood pressure down to such dangerously low levels that I started swooning constantly, like a heroine in a Victorian novel.

The pharmaceutical constant in my life became Fioricet with codeine. With its sister medication, Fiorinal with codeine, Fioricet has been on the market since the 1920s – both are time-tested treatments for migraine. Fioricet is based on acetaminophen, Fiorinal on aspirin; both have added caffeine, which can be effective in treating many kinds of migraine, and butalbital, a barbiturate that has a sedating effect.

Adding codeine to the mix intensifies the painkilling without turning it into as powerful a narcotic as, say, oxycodone. The result, many migraine patients have found, is an extremely effective drug.

Joan Didion came closer than anyone I know to capturing just what it means to live with incapacitating migraines. In her essay In Bed, Didion writes that she “went to school and later to work in spite of it, sat through lectures in Middle English and presentations to advertisers with involuntary tears running down the right side of my face, threw up in washrooms, stumbled home by instinct, emptied ice trays on to my bed and tried to freeze the pain in my right temple, wished only for a neurosurgeon who would do a lobotomy on house call”.

Yes, I said to myself, on discovering that essay, that’s what it’s like. But Fioricet helped me live something resembling a normal life throughout most of my 20s, 30s and 40s. With its help, during the 20 or so days a month when the migraine demons lurked, I could transform the “I think I’d rather be dead” pain into what others might feel was just a normal bad headache, and function – more or less. It’s still what I rely on when the Topamax doesn’t do its job as a preventative.

To my bemusement, however, Fioricet’s cost – never low – began to rise steadily. It began in 2003, at about the same time that Novartis sold the rights to the drug and its sister product, Fiorinal, to Watson Pharmaceuticals for $178m.

At the time of the transaction, Watson was described as having discovered that the sale of brand name medications of its own was “more profitable” than marketing generics, and it certainly seems to have tried to make money from its two new drugs: the price soared from $220 a month in 2003 to about $400 by 2005. It topped $500 by 2007.

That was when I switched to the increasingly available generics – which also promptly began to rise in price: from $75 to $90, then above $100 to $120.

Today, if I didn’t have insurance, I’d pay $150 for either of the two generic versions that my pharmacy could obtain; a third isn’t readily available via CVS. (Yes, two rival generic makers charge precisely the same amount, down to the penny. I’m sure it’s just a coincidence.) Meanwhile, the price of the 90-year-old brand medication has climbed to $945.

What is going on?

Getting an answer is far more difficult than it should be. It’s like putting together a jigsaw puzzle when someone has hidden two-thirds of the pieces.

In a just-published article, the Wall Street Journal quoted Robert Zirkelbach, a spokesman for Pharmaceutical Research and Manufacturers of America, as commenting that prices for all drugs eventually decline sharply when they lose patent protection and go generic.

Since Fioricet’s pricing pattern suggests that isn’t accurate, I asked the organization to explain the apparent contradiction. A spokeswoman directed me to a blogpost noting that “prescription drug prices fall significantly over time” and that generics typically cost 80% less than the brand. This failed to address the conundrum, but I received no response to my request for clarification.

In aggregate, generics may indeed help to cut the prices we must pay for the medications we need. Increasingly, however, the prices of those generics are rising, and when they cross certain thresholds, insurers like mine are telling their members that they must shoulder a larger proportion of those higher costs – even when it means a massive, 230% overnight price hike.

(Blue Cross Blue Shield of Rhode Island, for its part, didn’t disclose details of its pricing decision regarding Fioricet. A spokeswoman said only that the insurer takes a number of measures to try to limit such moves, including “advocating for policies that limit unsustainable drug price increases”.)

EvaluatePharma, a London-based consulting firm, noted that the generic versions of Fioricet and Fiorinal are among the generic drugs to have seen the largest price increases in recent months. But they are far from alone: much better known and more widely prescribed medications, like prednisone and digoxin, also have seen big gains.

The price of generic tetracycline, an antibiotic, soared 67-fold in a single 12-month period, from November 2013 to November 2014.

Par Pharmaceutical, the division of Endo International that makes one of the generic versions of Fioricet, was the only one of the several pharmaceutical companies involved in the production of either the brand or generic to return calls and emails seeking comment and an explanation for the migraine drug’s pricing.

In an email, Heather Zoumas Lubeski, senior director of corporate affairs, noted that Par (which previously marketed the drug under the Qualitest brand) recently lost its supplier of butalbital.

“Par then experienced a significant cost increase related to the new supplier,” she said, adding that Par also was hurt by cost increases at a manufacturing facility. Zoumas Lubeski didn’t provide any specifics on the magnitude of those price increases, when they began or the proportion of the cost of the medication that is accounted for by the butalbital.

But if I look back over years of prescription receipts, they show that Fioricet’s price increases are not a recent phenomenon. Allergan, which through a series of acquisitions and mergers has acquired the rights to manufacture the brand version, didn’t suddenly boost the price from $220 to $945: those increases have been steady and consistent over a dozen years.

The same pattern is visible in my records with respect to the generic drug. And the higher costs that Par experienced at its production facility shouldn’t have affected either Allergan or Breckenridge Pharmaceutical, the other generic producer.

Aaron Kesselheim, an assistant professor at Harvard Medical School and director of the program on regulation, therapeutics and law, said that it isn’t until there are at least four generic providers that Americans feel the benefits of having a generic drug on the market.

Only then, he said, can we count on being able to easily and affordably access the medications we need to survive or to have a reasonable quality of life. Without this level of competition, Kesselheim says, “prices of generics can still be very high, because whoever controls the supply can set whatever price they want”.

When a costly drug is the result of decades of research and development, it’s a bit easier to understand that its price will be high. Even so, it’s tough to grasp just how Vertex Pharmaceuticals determined that the right annual wholesale cost for its new cystic fibrosis drug, Orkambi, was $259,000 per patient.

Even though insurance will cut that cost, it’s a high price to pay for a drug that doesn’t offer a cure. But Vertex knows insurers will face tremendous pressure to cover prices they choose to set, given the nature of the disease, which kills many by the time they reach their 20s.

Even when patent-protected drugs aren’t new and revolutionary, the costs can be equally astonishing. Just ask Janet Burns: she analyzed precisely how a fungus that we’ve known about for millennia, ergot (which costs about 97 cents per milligram), is transformed into a migraine drug valued by its manufacturer at a retail cost of $3,600 – a markup of 11,600%.

The bottom line, in Kesselheim’s eyes, is that “there is no organization in the United States that declares what a reasonable price is for a drug. That allows manufacturers to set whatever price they think they can achieve”.

Moreover, negotiations between the industry and insurers feature “no transparency”, he says, and the Federal Trade Commission simply doesn’t have the resources to investigate cases where pricing seems odd, like that of the generic Fioricet provided by two companies at identical prices.

The bad news? The situation could get worse, and affect more drugs, more insurance companies and more consumers, as consolidation in the pharmaceutical industry reduces the number of potential rivals in the generic drug field. Today, Kesselheim calculates that the number of costly generics that have seen the kind of dramatic price moves as Fioricet with codeine might number in the dozens.

“With lack of oversight,” he says, “that might grow.”

Unless, that is, we start demanding answers to the question of just how some of these prices are set, and insist on more transparency.

Cases like Daraprim, which turned former hedge fund manager Martin Shkreli into one of the most hated men in America after he boosted the cost per pill of the toxoplasmosis drug from $13 to $750 overnight, may remain outliers, since only about 2,000 Americans actually take that drug every year.

Tens of thousands, perhaps, rely on Fioricet with codeine. The number of prescriptions written each year for generic versions prednisone, tetracycline and digoxin likely run into the millions.

For those of us filling those prescriptions, the price increases we’ve encountered are the toughest pills of all to swallow.