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pre­scrib­ing the two in­gre­di­ents in a sin­gle pill and that the sin­gle pill pro­tected pa­tients by mak­ing it more likely they would take their med­i­ca­tion as di­rected.

Hori­zon also primed the med­i­cal com­mu­nity by giv­ing dona­tions to­tal­ing $101,000 to the Amer­i­can Gas­troen­terol­ogy As­so­ci­a­tion, a spe­cialty non­profit for physi­cians. Some doc­tors refuse drug-in­dus­try money, if only to at least avoid the ap­pear­ance of a con­flict of in­ter­est. ProPublica has done loads of sto­ries show­ing why doc­tors tak­ing money is in­deed problematic, in­clud­ing one about drug mak­ers’ in­flu­ence on physi­cian spe­cialty groups. When I went on the Amer­i­can Gas­troen­terol­ogy As­so­ci­a­tion’s web­site, the first thing I saw was a pop-up ad from a drug com­pany. Sev­eral of the as­so­ci­a­tion’s board mem­bers have re­ceived drug-com­pany money, too. Hori­zon has made clear in its an­nual re­ports that dona­tions to the group “help physi­cians and pa­tients bet­ter un­der­stand and man­age” the risks of pain re­liev­ers caus­ing gas­tric prob­lems.

Hori­zon also ze­roed in on pa­tients’ wor­ries about drug costs. To en­cour­age them to fill their pre­scrip­tions, Hori­zon cov­ered all or most of their out-of­pocket costs. That’s why my doc­tor’s of­fice could prom­ise me I wouldn’t spend too much for my Vi­movo. The pro­gram, Hori­zon told in­vestors in re­ports, ad­dressed the im­pact of phar­ma­cies switch­ing to less ex­pen­sive al­ter­na­tives and could “mit­i­gate” the ef­fect of pay­ers search­ing for cheaper al­ter­na­tives.

The strat­egy worked on me. I didn’t even know why I was get­ting the pre­scrip­tion, but when they told me it wouldn’t cost more than I would spend on lunch with a friend, I gave it the OK. A phar­macy I’d never heard of sent me a bot­tle of Vi­movo for $10, even though my in­sur­ance com­pany re­jected the claim.

Turns out pay­ing the pa­tient’s costs mo­ti­vated my doc­tor, too. I waited un­til the end of my next visit to bring up Vi­movo, and then we had a fol­low-up con­ver­sa­tion on the phone. Ra­mani didn’t know the price of the drug and found it “dis­turb­ing” when I told him. That was a sur­prise to me, but not to him. He said he leaves billing to his staff and doesn’t even know how much he gets paid for a lot of the pro­ce­dures he per­forms, let alone how much in­sur­ers are be­ing charged for drugs. The mar­ket­ing arms of com­pa­nies like Hori­zon must count on this sort of blind­ness.

Ra­mani doesn’t re­ceive money or gifts from Hori­zon. (I con­firmed this on ProPublica’s Dol­lars for Docs web­site, which lists drug-com­pany pay­ments.) He said he likes Vi­movo be­cause Hori­zon cov­ers the pa­tient’s out-of-pocket costs, en­tirely in many cases. Pre­scrib­ing the gener­ics or over-the­counter med­i­ca­tions sep­a­rately would ac­tu­ally cost more, he said. Which of course is ex­actly the com­pany’s plan. But Ra­mani agreed that the high cost of the drug to in­sur­ers ul­ti­mately raises over­all health care costs for all Amer­i­cans.

Know­ing Vi­movo’s price, I asked him if he would con­tinue to pre­scribe it. “It changes my thought process,” he said. “But at the end of the day, I have to think about the pa­tient and whether the pa­tient will be able to pay out of pocket or not.”

Ra­mani said the Hori­zon drug rep told him Vi­movo pre­scrip­tions had to go through a par­tic­u­lar phar­macy for the pa­tient to re­ceive fi­nan­cial as­sis­tance. In its 2016 an­nual re­port, Hori­zon wrote that pre­scrip­tions for its drugs might not be filled by cer­tain phar­ma­cies be­cause of in­sur­ance-com­pany ex­clu­sions, co-pay­ment re­quire­ments, or in­cen­tives to use low­er­priced al­ter­na­tives. So that’s why they didn’t give me the op­tion of pick­ing up my pills at my neigh­bor­hood drug­store.

In­stead, my Vi­movo was mailed to me from White Oak Phar­macy in Nut­ley, New Jersey, which is about 45 min­utes from my house. I drove there to find out why. The neigh­bor­hood phar­macy is on the bot­tom floor of a twos­tory brick build­ing on a street corner, next to a hair salon.

Vishal Ch­habria, the phar­ma­cist who owns White Oak, told me the drug com­pany sets the price of Vi­movo. He in­sisted his phar­macy has no spe­cial re­la­tion­ship or con­tract with Hori­zon. Maybe the drug com­pany steers pre­scrip­tions his way, he said, be­cause his phar­macy will process the coupons that re­duce or elim­i­nate the pa­tient costs, which some phar­ma­cies don’t.

Ch­habria said there is no ap­proved generic al­ter­na­tive to Vi­movo, so he can’t sug­gest one to pa­tients. And while other drugs, like over-the-counter med­i­ca­tions, would be cheaper for the health sys­tem over­all, they are more ex­pen­sive for the in­di­vid­ual pa­tient, he said.

In por­ing through Hori­zon’s fi­nan­cial fil­ings, it ap­pears the drug’s run may be end­ing. Hori­zon said in its re­port for the first quar­ter of 2017 that fewer in­sur­ance com­pa­nies have been will­ing to cover Vi­movo and many that do have de­manded larger re­bates. As a re­sult, Hori­zon has been eat­ing more of the costs of pro­vid­ing the drug to pa­tients, as they must have in my case. The pre­scrip­tions have still been com­ing in, but net sales were just un­der $5 mil­lion in the first quar­ter of this year, down 81 per­cent from the first quar­ter of 2016.

Crit­ics of Vi­movo say that’s still more than pa­tients should be spend­ing on the drug. “That num­ber should be zero,” said Linda Cahn, an at­tor­ney who ad­vises cor­po­ra­tions, unions and other pay­ers to help re­duce their costs. “If you want to talk about waste, that’s waste.”

Her­rick, the health care econ­o­mist, said Hori­zon cashed in by elim­i­nat­ing many of the bar­ri­ers in the sys­tem that are meant to con­trol costs. The com­pany got pa­tients on board by cov­er­ing their out-of-pocket costs. It ap­pealed to doc­tors by pro­mot­ing the ben­e­fits to pa­tients. And it did an end-run around chain phar­ma­cies, which typ­i­cally might sug­gest a low­er­priced al­ter­na­tive, by steer­ing pre­scrip­tions to phar­ma­cists who would par­tic­i­pate in their pa­tient-as­sis­tance pro­gram.

“Some­body brain­stormed: ‘How can we nul­lify any con­sumer check and bal­ance in this sup­ply chain? What can we do to keep the cus­tomer from ask­ing ques­tions?’” Her­rick said.

The scheme that played out with Vi­movo is bound to hap­pen again, Her­rick said. Maybe it al­ready is. Drug com­pa­nies are al­ways on the look­out to de­ploy sim­i­lar strate­gies.

I du­ti­fully took my Vi­movo for sev­eral days, un­til I no­ticed it kept me awake un­til 3 in the morn­ing — a rare side ef­fect. (Per­haps they need to add a third drug to the combo.) I prob­a­bly have more than 50 pills left in the bot­tle on my bed­side ta­ble. Maybe I could sell it back to Hori­zon for $1,500.

Mar­shall Allen is a re­porter at ProPublica in­ves­ti­gat­ing the cost and qual­ity of our health care.

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