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In my last column, I looked at the tremendous variation in prices among pharmacies for two psychotropic medications, aripiprazole and modafinil. The cash price variation could be as much as 45 times more from one pharmacy to the next, which I found to be both outrageous and incomprehensible. Hirsch with two simple questions. I wanted to know 1 Who pays for this difference in the medication cost, and 2 How does the company, with 95 employees, make any money? Hirsch was gracious enough and patient enough! Medications are made by a pharmaceutical company or, for generics, there may be many manufacturers. The medications are sent to a pharmaceutical distributor, such as McKesson, and it, in turn, sells and delivers the products to pharmacy chains, as well as to smaller, independent pharmacies. Physicians are familiar with PBMs, who intercede by requiring preauthorization procedures for certain medications or by instituting stepwise, fail-first, requirements before they will allow pharmacy benefits toward the purchase of medications. I hope you are still with me, because this is the part of the conversation where I started telling Mr. Hirsch that I was getting a headache.

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