If you would like a beautiful example of just how utterly screwed up the American market in prescription medicines is, consider my experience this week.

I take a drug called Diltiazem to control my way-too-high blood pressure. It’s a common drug, highly effective, taken by millions, and has been in the pharmacopeia for decades. Being generic, the cost, at least by drug standards, is very little; about $60 for a 90-day supply.

Then my doctor decided to up my dosage from 240 milligrams to 360 milligrams. The new prescription cost $558 for a 90-day supply, over nine times as much.

Naturally, I called up the on-line pharmacy to ask why a 50 percent increase in dosage should result in a 930 percent increase in cost. The explanation was that Diltiazem at 240 milligrams is a “Tier 1” drug, but that at 360 milligrams it’s suddenly a “Tier 3” drug, so it costs over nine times as much. The pharmacy advised me to ask my doctor to prescribe 120-milligram capsules to be taken three times a day instead of 360-milligram capsules to be taken once a day, bringing the price down to the old level.

The manufacturing costs of 120-milligram capsules are, surely, exactly the same as for 360-milligram capsules. So this is like a supermarket charging $1 for milk in quart containers and $36 for milk in gallon containers.

Economically this makes no sense whatever. Politically, somehow, I imagine it does.

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