Then the drug companies come in and offer a "savings card" which you apply at the pharmacy like another layer of insurance. I searched and Miebo has one too: https://miebo.blsavingscard.com/ You'd have to read all the fine print, but it reveals that the actual cash-pay price is $225 (still high, obviously) and they have a co-pay assistance program that reduces your copay to $0 to incentivize you to get your insurance billed for this drug. So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.
The FDA is partially to blame for this situation: They required a complete New Drug Application before they would let anyone bring it to market, even though it's over the counter in other countries.
The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.
So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.
The equivalent of the same in the US, I was told 200USD in the US using Insurance, and I bought it for 40USD via GoodRx App without Insurance. https://www.goodrx.com/ciprofloxacin
() Biden's inflation act gave Medicare permission to start negotiating drug prices in 2026. Who know what the current US Administration will do though.
That being said, US drug prices are 2-4 times higher than they are elsewhere. In fact, the US market essentially subsidizes international drug markets, where it is much more difficult to charge higher rates due to regulations and lower purchasing power. This also means that, even if the allowed price in the US were known in this example, it would still have to be PPP adjusted to be compared.
Prescription card coupons such as those you get from GoodRx et al apply only to cash prices. These are sometimes lower and sometimes higher than what you’d pay out of pocket with your insurance. to compare, you’d basically have to ask the pharmacy to ring up a drug twice, once with cash price + coupon and once with insurance price.
“Copay assistance” are programs by drug manufacturers, PBMs, or employers to defray the cost of drug prices. This is usually done for specialty drugs that are much more expensive and can often only be purchased from a mail order pharmacy designated by the payer. For example, United Health (left pocket) will only cover the drugs if you get them from their Optum Specialty Pharmacy (right pocket).
As for numbers, here an example: I’m receiving a monthly specialty drug that my insurance is billed ~$9,000/month. In order to arrive at that figure, the drug company proposed, say, a $50k/month list price, and my insurer countered with $9k, using the size of their member pool as leverage. Of course, the drug manufacturer knew they would arrive at approx that figure, which is why they started negotiating that high. Well, sorta. The PBM gets compensated based on a % of the “savings” (spread between list price and final price), so naturally, they want as high as possible a list price, because 5% of a big amount (in my example: $50k-$9k = $41k) than 5% of a smaller amount. Because the PBM often has most of the leverage, the drug manufacturers (most of whom actually dislike PBMs) have to go along with this stupidity.
How much of the $9k I pay depends on a variety of factors, including my insurance plan, which has a specialty drug tier. This means the drug is not handled via the cost sharing accounting mechanism (deductible/copay).
Now, through that specialty tier, my monthly responsibility is set at approx $1,300. I’m not privy to the math behind this, because my insurer has outsourced all drug-related administration to a PBM, which is only loosely regulated and doesn’t even have to issue explanation of benefit statements that would normally disclose the full accounting.
Of the $1,300, I pay nothing, because the drug manufacturer provides me with a copay assistance card. Again, they must keep the list price high to placate the PBM.
I’ve simplified a few things here. For instance, there are now alternative comp models for PBMs. But for those, PBMs have also found ways to manipulate the system in their favor (eg colluding with drug manufacturers). There’s also often a wholesaler involved in the “value” chain.
But by and large, this is roughly how it works…
And yes, individual market plans are substantially inferior. Not only do they have lower actuarial values and higher cost per $ of coverage (which is unavoidable, because they are not risk pools) and narrower networks, but they also usually have built-in mechanisms to further prune away coverage in many subtle ways (they have that in common with self-insured plans): - more prior approvals, - “step therapy” (must first not tolerate cheaper drugs before can receive pricier drug), - not covering the pricier drug tier at all, etc.
These things shave some dollars off the premium, which appeals to price-elastic consumers and employers.
https://en.wikipedia.org/wiki/The_St._Regis_Mohawk_Tribe_and...
But it is absolutely revolutionary if you have dry eyes. Quotes include "I feel like my eye is actually too wet now"
1. heinously addictive
2. incredibly dangerous when not used exactly correctly
3. an antibiotic (due to the resistance externality)
And for drugs that do meet one of these conditions, doctors should be able to write lifetime prescriptions for cases where the medication is used to treat a permanent condition. This probably covers 95% of non-antibiotic prescriptions. The savings from removing the gatekeepers in terms of time and money would be massive and the costs would be minimal.
[1] - https://fourthievesvinegar.org/
[2] - https://www.youtube.com/watch?v=5rQklSmI_F0 [video][1hr16m][DEFCON 32]
the article does a good job of showing the self serving double speak and the lack of pursuing an OTC option in the US, but I want to compare costs directly, since the article also acknowledges that OTC would have been much cheaper than $800 in the US too
in that case, you don't care if you drug cost 10€ or 2000€ because you aren't spending a single € from your own wallet, at least if you don't factor in taxes.
Contrary to the USA where it's a much more responsible market, people do pay for the medications or they get it paid by their own insurance but it cost them directly a lot of money.
I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing. That's just how free market work, and technically there are many medication manufacturer and many customer.
Is it the proof that a true unregulated free market doesn't work ? if left unsupervised, big companies are going to buy smaller companies until they are monopoly or make secret, behind the door, deal to keep price up.
It's what the USA is made on, the idea of freedom and free market. i believe the idea of unregulated market is more recent, think the 70's, but surely in the 50 years since then american would have pushed back against it and not elected people like Trump who are all in.
The US today is structurally dependent on this sort of cash migration. If all Americans suddenly began to save 10%+ of their income every month (also structurally impossible for most), GDP would dramatically contract.
These things aren't broken. They are by design.
Sure, we do not pay $800 at the pharmacy when we go to pick up the prescription, but every cent the insurance company pays, we are paying by proxie with added admin costs.
For example, my partner needs $100/pill medication, which also had a "savings card." That card only lasts for 12-months or 8-pills (whichever comes first). Then it is $100/pill. After insurance (High Deductible), we pay out of pocket $100/pill up until $3200. Insurance discount: 0%.
So the cash price and the insurance price are identical, except the insurance price counts towards deductible. UK price of the same medication? £10/pill, and that isn't via the NHS, that is full-price private (NHS could be as low as FREE, depending on several factors).
> The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.
> So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.
It's interesting that you seem so passionate about this because you're totally incorrect. The cost of a NDA for a novel prescription drug requiring clinical data (the most expensive application) is ~$4.5mil. In fact, the estimated TOTAL revenue to the FDA from ALL PD application fees in FY 2025 is ~$1.3billion (or, just under 300 novel prescription drugs). So, obviously, FDA fees can't be as much as you're claiming.
What you're actually describing is the total cost of the entire drug development pipeline (research, design, lab costs, chemical costs, application costs, marketing costs, etc.) to develop a brand new, novel drug. And it's only ~$200m, increasing to $500m if you include dead ends / failures in the process, and ~$900m if you include both failures and capital costs--yep, that's right the capital costs alone are almost as much as the entire rest of the drug development pipeline.
See: https://jamanetwork.com/journals/jamanetworkopen/fullarticle...
And that's for novel Prescription Drugs.
> They required a complete New Drug Application before they would let anyone bring it to market, even though it's over the counter in other countries.
No. In that case they would pay the FDA OMUFA fees, not the FDA PDUFA fees, which are ten to fifty times cheaper than the PDUFA fees.
I should be allowed to buy front line antibiotics from the grocery store. It’s infuriating that this is not possible..
The overhead of selling to the government is significantly higher than selling to private companies. So the government simultaneously demands the lowest price while having a much higher cost of sales that needs to be covered by that price. A price that would cover the cost of selling to the government would be non-competitive if selling it to a private company because you may be competing with other companies that don't have to anchor their prices to the cost of doing business with the government.
To work around this companies post a very high list price, no lower than what they charge the government as required by MFN regulations. They then effectively steeply discount those prices when selling to other entities via various mechanisms to more accurately reflect the lower cost of sales. The list price is a fiction required to satisfy "most favored nation" pricing laws, no one is expected to pay it.
tl;dr: In many cases the basic economics requires the government to be charged more than average because they are expensive customers with high overhead. MFN regulations don't make this reality go away so companies have to creatively structure their pricing to satisfy regulations without requiring non-government customers to pay for government overhead.
We're gonna be so rich!
There is a weird thing Americans often do when confronted with the incredibly high price of medicine and medical care in the US of imagining that every other country is actually responsible for this (hence the "most favored" nonsense). That it's zero sum and every other country is laughing and taking Americans for a ride and underpaying, and therefore Americans have to cover the bill.
This is the angle Trump has taken in some of his incredibly ignorant and stupid screeds on this topic (as with every single position he has on anything): Get everyone else to pay more and somehow the US pays less!
This...isn't at all how it works, or what the problem is. Americans pay more because of the whole massive scam of your Medical Insurance Racket, where everything has imaginary inflated prices and an absolutely massive middle-tier of suits having nothing to do with medicine are taking their cut. This is your problem, reflected almost nowhere else on the planet, and it is domestic caused and will need to be fixed domestically. Criticizing Europe or Canada or anyone else will never, ever fix the utterly, insanely broken and profoundly stupid American system.
But it won't. It's simply incredibly how easily Americans can be fooled into voting against their own best interests, year after year.
You’re basically saying the drug companies subsidise a loss in Europe by over charging Americans, right?
As the drug company is a private and doesn’t have to sell everywhere, why wouldn’t they just skip the loss making Europeans and just sell to Americans? They’d make more profit that way!
That must mean they make some profit from the European prices, otherwise they wouldn’t be bothering.
Back of envelope, if the total cost of that drug went solely to profit, and profits were cut in half, it would cost $200 for both Europeans and Americans if we paid the same price.
So yeah, we are kind of subsidizing the lower prices for Europe.
The whole PFAS scare is waaaaay too overblown.
You could actually order this from amazon.de up until recently and have it shipped to you. That seems to have disappeared, though.
In my EU country I get a subsidy of at least two thirds on most drug prices with a state prescription. But the nominal cost is already negotiated down by state purchasing, and I suspect there's some EU cooperation there. So it's impossible to say what the "normal" price would be.
The cost of the paperwork depends on your doctor. I pay €3 for new paperwork a few times a year.
You can get many drugs OTC here without a prescription - more expensive, but it always surprises tourists who suddenly discover they can get many common meds (except for things like antibiotics and steroids) just by asking.
This is why I always check to make sure it's fiscally responsible before I start chemotherapy, or before buying that emergency inhaler for asthma, or before accepting paralytics and anesthesia when undergoing surgery. How fortunate that in America diabetics have the freedom to die rather than take overpriced insulin. Let the free market decide which child with leukemia deserves a bone marrow transplant and which deserves a casket! That's a much more responsible market than just having everybody chip in a small amount so that nobody needs to worry about the cost of the medications they need to live. Sure, in America millions will die or be bankrupted by healthcare costs every year, but that's better than spending a single $ from your own wallet if even a tiny fraction of it might help pay for someone else's medications right?
> Is it the proof that a true unregulated free market doesn't work ?
The market is heavily regulated (frequently crazily) by the FDA, and the actual amount anything costs is heavily obscured from the eyes of any consumers by the fog of bureaucracy and insurance.
Many people have 3-4 tiers of fixed copays that the insurance company makes up - some pharmacies won't even tell you when there is a cash price or a "coupon" that would be cheaper than your insurance copay! And pharmacies don't publish a plain list of what the cash prices are, and it would be hard for most people to even produce the tier formulary, it's buried as a PDF in some obscure page of a horrible website. So we just go to the pharmacy and see what it'll cost us.
Also, one major insurer owns a major pharmacy benefits manager and one of the big 2 pharmacy chains, so they use that to put their thumb on the scale however they can, while the other insurers and PBMs play games to lock consumers into restrictive exclusive deals that are to their detriment.
Anyway we don't have a market at all when it comes to healthcare, because the majority of price information is withheld from consumers until the opportunity to make any choice, if it even existed, is well past.
That's the idea, but in practice there are so many layers of indirect government incentives, disincentives, and direct interventions that market is no longer effective for this purpose.
It's virtually impossible to find out how much a medical procedure actually costs. Most hospitals and clinics refuse to even estimate as a policy, which has led to the creation of things like pre-paid services for labor and delivery. Those are quite rare.
I'm 100% in favor of allowing the market to work - but at this point, we have the worst of both worlds and the best of neither. Either extreme would be better than what we have.
When you have 30 insurance companies, 10000 companies buying insurance policies and millions of individuals - you get shit prices.
That's why the drug in question is 200 USD in US (after deductions) and 20 in Europe (including taxes).
This isn't really true on obamacare/ACA plans, even the high-end ones like gold PPOs. The formularies are much worse than employer-based plans. Insurers are required to cover one drug in each therapeutic category, but its usually an older generic. Most brand name drugs like this one have really bad coverage or not at all, which means the insurer won't even negotiate with the pharmacy to lower the drug.
Yes you can use coupons, sometimes, but the pharmacy can't always process them and the manufacture is always change the conditions and expiring them. I got one for my glaucoma drops directly from my eye doctor, and it was expired immediately when I tried to use it. I have paid $650 (for a 3 month supply, the full retail cost) for my drops when the coupon didn't work, and I couldn't get them any other way - I can't interrupt the med or else my eyes get damaged. So that falsifies your "nobody" assertion.
They do not pay $0 because the insurance company raises the rates for all of their customers to cover the cost of all the red tape and time spent negotiating with drug companies over their bullshit. The insurance companies aren't eating those costs, they're profiting from them and it's us who end up footing the bill. By the time you factor in the unnecessary time, staff, record keeping, etc. the actual cost for the $20 drug will be even more than the $800 sticker price.
No matter how our crooked system twists things to make it look otherwise they always make you pay. One way or another.
Visomitin (Emoxipine/Mexidol) eye drops are a Russian-developed antioxidant medication known for treating dry eyes, fatigue, radiation damage, and improving vision, working to protect eye cells from damage (oxidative stress), but it's not widely available or FDA-approved in the US, requiring international purchase or specific prescriptions, often used for cataracts or post-surgery recovery, focusing on cell protection rather than just lubrication like many Western OTC drops.
Also, aren't most mostly benign drugs dangerous when combined with the wrong other mostly benign drugs? The gatekeeping protects against that.
(Not american) This assumes they have a choice, no? Do these medications have real alternatives?
That's pretty much the entire business model of GoodRx.
80% of prescriptions are controlled by 3 companies. You can look up the FTC report on it. All three of them own or are owned by insurance companies.
The insurance companies had their profit percentage capped, and so the only way they could increase profits was by increasing their share of the pie. So they bought medical providers and prescription companies.
Now the insurance company is both the buyer and the seller, but not the one who pays. We pay. So they raise the prices of the drug, raise the cost of insurance, and make a lot more money while staying in their profit percent cap.
All the way around, this is the opposite of a free market and the FTC should be breaking these companies up. And as everybody knows, all the way around, it is immoral, too.
On the flip side, before I transferred my prescriptions to my (excellent) locally-owned small pharmacy, I checked that these are drugs on which the respective Pharmacy Benefits Manager allows them to make a profit rather than a loss. That reminds me that I'll need to repeat that conversation when our insurance changes in January.
https://www.boots.com/boots-ibuprofen-caplets-400mg-96s-1026...
And if you're a fan of Benadryl (diphenhydramine), don't expect to buy it in Latin America. It virtually doesn't exist.
https://www.chemicalbook.com/ProductDetail_EN_1-perfluorohex...
Add analytical lab services to analyze it for purity and you could still get a lifetime supply for the price of a couple of brand-name bottles. This is the sort of thing that some Americans have been doing to get cheap GLP-1 peptide drugs from overseas too.
Maybe the next dem president will write an executive order directing the HHS to drop the enrollment age for Medicare to zero.
The price of drugs that make it to market needs to not only cover the cost to produce the drug, but also the cost of R&D and the cost of R&D of all the drugs that fail to get to market.
Now this gets complicated when a company sells in different markets with actors that have different negotiating power. It makes sense to sell in any market where the company can get a profit per unit sold without including R&D. But if none of the markets allow enough profit to cover R&D, then it's not really worth developing any new drugs at all anymore.
That's why people say that the US is basically subsidizing drug development. It's not that it's not profitable to sell in the rest of the world, it's just that margins are much lower which allows for a lot less risk-taking on R&D.
this argument is easily dismissible for any product that has high fixed costs but low marginal costs
which applies to a lot of drugs
But to engage seriously:
> You’re basically saying the drug companies subsidise a loss in Europe by over charging Americans, right?
No - once they know how to manufacture a drug, it's dirt cheap for them to do so - they're still making a profit in Europe. The purpose of billing Americans a huge amount (other than they can get away with it), is to fund the research + trials for the next generation of drugs.
Of course, even this argument doesn't hold water. I remember when pharmaceuticals spent more on advertising/marketing than on R&D (may still be the case).
And these aren't necessarily old pharma hand-me-downs. There are lots of novel and strange drugs (9-MBC, lol) that you can buy for next to nothing.
An NDA requires peer-reviewed studies, and something that looks at least a little like scientific rigour.
Of course we could just not bother with that.
Is that really a smart thing to do?
I do believe your question is false, we don't spend a tiny amount of our money on healthcare.
Around 20% of our revenue, in France, goes to the universal healthcare.
And yes, I would rather manage that money myself because I believe I am better at doing so that my government. Isn't that one the core beliefs of Americans ?
The issue is that there must an actual free market, enforced by government, and not some kind of oligarchy where drug price are kept artificially high amongst reseller.
There are some market pressures in healthcare when multiple companies can compete, although it's so heavily regulated it can be hard to see the market pressures in practice. Consumers often do have some amount of choice though
That's absolutely incredible. Yeah if you can't even get a pricing,i don't see how you could make any decision whatsoever.
We're not far from half the US population having what amounts to universal healthcare already, even without making it official. I sometimes wonder how high it will get before people come to the realization that we're already close enough to that point and going the rest of the way is viable.
I like to take a peek at it every so often and it's just stupendously worse than employer healthcare. There is no plan in my market (Idaho) which doesn't have extreme out of network deductibles. The cost is also identical to what I and my employer pay for insurance.
Is it just that the ACA is mostly used by sick people or something?
I wouldn't care if I ended up paying more in tax than I would in an insurance model. The benefit is being able to 100% focus on my health instead of navigating a system to try to reduce what I'm paying.
When you're diagnosed with an illness, that's a huge peace of mind.
It's more efficient to allocate capital to systems and processes that delay or stop you claiming on your insurance than it is to actually pay out a genuine claim.
Ha, that's funny, I do something kind of like that when I go to the UK. Though it's just one medicine -- Kwells. Easily available OTC there, not available at all here in the US except as a prescription-only transdermal patch.
As a counter-example, up until fairly recently you could buy Co-codamol (codeine, an opioid) in the UK off-the-shelf (i.e. no script). Which is a controlled substance.
See how people can use selective examples to play the "one system good, one system bad" game?
Europe is a big place, buddy. Which particular part are "we" from today?
NHS England has NICE (National Institute for Health and Care Excellence), which does the cost-benefit analysis for all medicines prescribed, nationally. It frequently decides medicines aren't worth the money. If you, as a private citizen, want that particular medicine, you can waste your own money on it. NHS England does not have a moral hazard problem.
The NHS also spends money trying to convince people to exercise, eat well, lose weight, not smoke, look for early signs of cancer, etc., because they find that relatively tiny amounts of money on these campaigns results in massive, massive savings from not having to treat so much preventable disease later in life.
I’m the plus side, all bronze plans can contribute to HSAs next year.
We compared individual plans off market, but they’re mostly the same without HSA access or they’re targeting people with specific ailments (e.g. the diabetes plan).
On top of that, consolidation of hospital systems has made wait times for GPs months unless you’re lucky enough to find a cancelation. We have some older Canadian ex-pat friends and it seems like our health system has all of the downsides of socialized systems, plus we get to pay Cadillac prices.
I’m really hoping 2026 is so bad that something breaks enough to resolve some fundamental issues with private health costs, but I’m not naive enough to think it’s likely. ACA was such a monumental gift to someone, but it definitely not individuals who need family coverage.
So my guess is this is heavily state dependent. Maryland as a state isn’t hostile to ACA so I think they have solid plans.
I can also only speak for BlueCross plans.
* https://news.ycombinator.com/item?id=44604365
* https://news.ycombinator.com/item?id=44989706I'll take a queue over bankruptcy any day. And these queues people complain about are triaged - if you're dying you skip to the front. The complaints about waiting hours are from people with broken arms, and at least they get seen and their arms get fixed, for free or a nominal price.
"First, they came for the gatekeepers. Then, they came for the billionaires."
This is the "exception that proves the rule" I guess
One of the best OTC medicine for motion sickeness hand down
Dramamine is (almost literally) a bad joke
One big benefit, though, is you can legally import or bring in POMs from overseas, a luxury the US does not have.
But in terms of cost, the US system is bad. If we as a nation want to invest in drug development, we should do so. Instead we ask grandma and grandpa and the chronically ill to flip the bill. Hard to think of a worse approach.
Indeed, plenty of peptides that aren't really well tested in humans (in some cases, like at all). And some that have tests in foreign countries but are not recognized by the FDA (like Selank and Semax, which are nootropics). And if you want to get ahead of the curve, you can buy things like retatrutide already even though it hasn't quite completed Phase III tests yet so Lilly isn't able to sell it to you. If you hunt a little, you can even buy orforglipron now.
It is quite fascinating to watch. A lot of people are very willing to experiment on themselves. And it seems like GLP1s end up being a gateway drug -- people go to the gray market to get it cheap, and then they cave to temptation and try some of the other stuff they can get the same way.
Because pre-existing conditions have to be covered, you're free to wait until you have a serious (expensive) condition, then sign up for an ACA plan. And there's no mandate that spreads that risk around to healthy people, so the population is severely skewed.
I have no definitive data on this, but it seems self-evident that the system can't work well.
What about Warfarin? Its $21 for 30 pills, according to https://www.goodrx.com/warfarin
I wouldn't recommend it. A quick search shows that it's not proven to do anything at all but it's also advertised as being the cure for parkinson's, asthma, back pain, high cholesterol levels, anxiety, blood clots, glaucoma, and Huntington’s disease while also making you smarter and improving your memory. This sounds like classic snake oil. Something I'd expect to see being sold alongside Horny Goat Weed and kratom at a gas station rather than an actual medication dispensed by a pharmacist. As fucked up as the American healthcare system is I guess you really have to hand it to Russia sometimes.
Five states plus DC still have an individual mandate (ugh), and yes health insurance premiums are spiking there too. A large part of that is due to the tax credits (generously labeled subsidies) expiring – even with an individual mandate health insurance is prohibitively expensive.
Almost 10 years of treatment for a health condition, and the only forms I've ever filled in were:
1. Legal risk document to say I understood the risks of treatment
2. Change of address form
3. Form to say I wouldn't impregnate people while on a certain medication
So yeah, removing that source of pollution is good. At the same time, the effects of even the worst offender (PFOS) are at most mild. Wildlife and epidemiological studies found significant effects only in areas that are at least billions of times more contaminated with PFAS than can ever accumulate in the environment if the waste streams are managed properly.
The lipid emission will heal partially if one supplements vitamin A (10k IU) softgel, omega-3 triglyceride ester, taurine, and at least 4K IU of vitamin D3. It will heal enough to work. The D3 in this dose is for freezing autoimmune degeneration.
I have severe dry eye and I never need any drops except if I am wearing contact lenses.
California has an excellent non-profit option, and it depresses prices a bit, but not a huge amount
A month’s supply of Miebo, Bausch & Lomb’s prescription dry eye drug, costs $800 or more in the U.S. before insurance. But the same drug — sold as EvoTears — has been available over-the-counter (OTC) in Europe since 2015 for about $20. I ordered it online from an overseas pharmacy for $32 including shipping, and it was delivered in a week.
This is, of course, both shocking and unsurprising. A 2021 RAND study found U.S. prescription drug prices are, on average, more than 2.5 times higher than in 32 other developed nations. Miebo exemplifies how some pharmaceutical companies exploit regulatory loopholes and patent protections, prioritizing profits over patients, eroding trust in health care. But there is a way to fix this loophole.
In December 2019, Bausch & Lomb, formerly a division of Valeant, acquired the exclusive license for the commercialization and development in the United States and Canada for NOV03, now called Miebo in the U.S. Rather than getting an approval for an OTC drug, like it is in Europe, Bausch secured U.S. Food and Drug Administration approval as a prescription medication, subsequently pricing it at a high level. Currently, according to GoodRx, a monthly supply of Miebo will cost $830.27 at Walgreens, and it’s listed at $818.38 on Amazon Pharmacy.
The strategy has paid off: Miebo’s 2024 sales — its first full year — hit $172 million, surpassing the company’s projections of $95 million. The company now forecasts sales to exceed $500 million annually. At European prices, those sales would be less than $20 million. Emboldened with Miebo’s early success, Bausch & Lomb raised the price another 4% in 2025, according to the drug price tracking firm 46brooklyn.
Bausch & Lomb has a track record of prioritizing profits over patients. As Valeant, its business model was simple: buy, gut, gouge, repeat. In 2015, it raised prices for Nitropress and Isuprel by over 200% and 500%, respectively, triggering a 2016 congressional hearing. Despite promises of reform, little has changed. When he was at Allergan, Bausch & Lomb’s current CEO, Brent Saunders, pledged “responsible pricing” but tried to extend patent protection for Allergan’s drug Restasis (another dry eye drug) through a dubious deal with the Mohawk Indian tribe, later rejected by courts.
Now at Bausch & Lomb, Saunders oversaw Miebo’s launch, claiming earlier this year in an investor call, “We are once again an innovation company.” But finding a way to get an existing European OTC drug to be a prescription drug in the U.S. with a new name and a 40-fold price increase is not true innovation — it’s a price-gouging strategy.
Bausch & Lomb could have pursued OTC approval in the U.S., leveraging its expertise in OTC eye drops and lotions. However, I could not find in transcripts or presentations any evidence that Baush & Lomb seriously pursued this. Prescription status, however, ensures much higher prices, protected by patents and limited competition. Even insured patients feel the ripple effects: Coupons may reduce out-of-pocket costs, but insurers pay hundreds per prescription, driving up premiums and the overall cost of health care for everyone.
In response to questions from STAT about why Miebo is an expensive prescription drug, a representative said in a statement, “The FDA determined that MIEBO acts at the cellular and molecular level of the eye, which meant it had to go through the same rigorous process as any new pharmaceutical — a full New Drug Application. Unlike in Europe, where all medical device eye drops are prescription-free and cleared through a highly predictable and fast pathway, we were required to design, enroll and complete extensive clinical trials involving thousands of patients, and provide detailed safety and efficacy data submissions. Those studies took years and significant investment, but they ensure that MIEBO meets the highest regulatory standards for safety and effectiveness.”
Bausch & Lomb’s carefully worded response expertly sidesteps the real issue. The FDA’s test for OTC status isn’t a drug’s mechanism of action — it’s whether patients can use it safely without a doctor. Miebo’s track record as an OTC product in Europe for nearly a decade shows it meets that standard. Bausch & Lomb provides no evidence, or even assertion, that it ever tried for OTC approval in the U.S. Instead, it pursued the prescription route — not because of regulatory necessity, but as a business strategy to secure patents and command an $800 price. In doing so, B&L is weaponizing a regulatory loophole against American patients, prioritizing profit over access, and leaving their “significant investment” as the cost of monopoly, not medical necessity.
Even if you accept Bausch & Lomb’s self-serving rationale, the answer is not to allow the loophole to persist, but to close it. The FDA could require any drug approved as OTC internationally be considered for OTC status in the United States before greenlighting it as a prescription product — and mandate retroactive review of cases like Miebo.
The FDA’s OTC monograph process, which assesses the safety and efficacy of nonprescription drugs, makes this feasible, though it may need to be adjusted slightly. Those changes might involve incorporating a mechanism to make sure that overseas OTC status triggers a review of U.S. prescription drugs containing the same active ingredients or formulations for potential OTC designation; developing criteria to assess equivalency in safety and efficacy standards between U.S. OTC requirements and those of other countries; and establishing a retroactive review pathway within the monograph process to handle existing prescription drugs already marketed OTC internationally.
EvoTears thrives abroad without safety concerns, countering industry claims of stricter U.S. standards. This reform would deter companies from repackaging OTC drugs as high-cost prescriptions, fostering competition and lowering prices.
While this tactic isn’t widespread, it joins loopholes like late-listed patents, picket fence patents, or pay-for-delay generic deals that undermine trust in an industry whose employees largely aim to save lives.
Miebo also shows how global reference pricing could save billions. Aligning with European prices could cut consumer costs while reducing doctor visits, pharmacy time, and administrative burdens. For patients who skip doses to afford groceries, lower prices would mean better access and health. Reforms like the 2022 Inflation Reduction Act’s Medicare price negotiations set a precedent, but targeted rules are urgently needed.
Unexplained differences in drug prices between the U.S. and other wealthy countries erode the public’s trust in health care. Companies like Bausch & Lomb exploit systemic gaps, leaving patients and payers to foot exorbitant bills. An OTC evaluation rule, with retroactive reviews, is a practical first step, signaling that patient access takes precedence over corporate greed.
Let’s end the price-gouging practices of outliers and build a health care system that puts patients first. Just as targeting criminal outliers fosters a law-abiding society, holding bad pharmaceutical actors accountable is crucial for restoring trust and integrity to our health care system. While broader approaches to making health care more fair, accessible, and affordable are needed, sometimes the way to save billions is to start by saving hundreds of millions.
David Maris is a six-time No. 1 ranked pharmaceutical analyst with more than two decades covering the industry. He currently runs Phalanx Investment Partners, a family office; is a partner in Wall Street Beats; and is co-author of the recently published book “The Fax Club Experiment.” He is currently working on his next book about health care in America.
How is it possible to have 300$ Vial ? Sanofi ain't exactly a charity and they are doing extremely well financially, 300$ is obscene. If they sell it at 300$, there must be people buying it. Who are they ?
Never paid a cent, never had a single call or piece of paper for logistics or payment or any of that bs.
She was a teacher her whole life, middle class, no private insurance ever.
It can be, and is, phenomenal in countries that do it right.
Aim higher.
I do.
1. "PFAS" is a technically incorrect term. 2. It's ridiculously broad. Teflon is PFAS, sevoflurane is PFAS, and so on.
> If you actually think the scare is overblown, I dare you to drink the whole bottle of that eyedrop.
They literally use the same liquid to FILL THE EYEBALLS after retinal surgery. It's been approved for 25 years. A bottle of eyedrops has 4 milliliters of it, and it would do essentially nothing if swallowed.
> The lipid emission will heal partially if one supplements vitamin A (10k IU) softgel, omega-3 triglyceride ester, taurine, and at least 4K IU of vitamin D3. It will heal enough to work.
Omega-3 acids help a tiny bit, and I'm getting D3 and A from multivitamins. And I'm doing all other recommended stuff: eyelid washing, compresses, IPL, etc. Over the years, I tried discontinuing all of that a few times, and my symptoms worsened as a result. But not by much.
PFHO is the most effective "artificial tears" type product. Nothing comes close to it.
In Canada all of our best doctors go to the US and there's often nurse shortages. It's not just a private incentive either, the US gov pays out far more in public healthcare coverage as a percentage of GDP and per capita than Canada and almost all of Europe.
Despite their reputation the US doesn't have a lack of public healthcare spending (ranking #1-3 in the world). It's just their system's insurance regulation is extremely convoluted, creating risky edge-cases and perverse incentives. If they fixed that they would by far have the best healthcare system in the world.
Exactly! This is what no one in the US seems to understand. My encounters with private clinics and hospitals in the UK (all 10+ years ago, at this point) were unbelievably luxurious, at prices that (totally, completely free-market driven, mind you) were affordable on middle-class incomes. Or, yeah: there's private medical insurance, also free-marketed to "shockingly reasonable", by US measures. Americans on good salaries have been bamboozled into believing that a single-payer system will trap them into some kind of hell-hole hospital° with no recourse, when in fact the exact opposite is true.
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°And, of course, the "hell-hole hospital" examples are cherry-picked. Bad on their own, of course, but not representative of a system as a whole, nor recognize that equally awful anecdotes are abundant in the USA.
https://www.cbpp.org/research/health/the-medicaid-coverage-g...
Still more expensive than the rest of the random Chinese vendors, but the upshot is that participation rates are very good for Nexaph and so there's a lot of testing done -- especially for GLP1s. For example, the current batch of Tirzepatide 60mg will have a 3- or 4-vial COA done by Nexaph themselves, another 3-vial random sample tested by customers (but then compensated by Nexaph), and at least one and maybe two big group tests with 7+ vials doing a full range of mass/purity/endo/sterility testing.
I've not seen too many other vendors that get such a high participation rate. And even for this company, for non-GLP1 peptides it's still tested pretty well but not to the same extent.
Even at their expensive price point, you could buy a few kits (10 vials ea) and pay $1000 for a full suite of tests and still be into it about $80/vial total, where a vial is ~65mg and lasts most people at least a month. Do the math on that -- compared even to cheap compounded tirz it is a fraction of the cost. There is good reason why a lot of people are taking that route now.
And back to your original question - once you are on the Telegram group, ask around and people will invite you to other Telegram and Discord groups for various vendors.
Or go to glp1forum.com and a lot of the same vendors will have posts there with information on contacting them.
The main expense is proving your drug works. It’s not really fair to describe that as incurred by FDA regs.
And in any case: drugs are (surprisingly) not a major driver of healthcare costs in the US.
The things that are uniquely costly in American healthcare are administrative overhead and doctors + nurses.
Go read KFF reporting on it.
I went to see my GP, paid for by public health, they referred me to a specialist.
I chose to pay €100 to see a private doctor who was available sooner (the next day) and had better ratings.
They referred me for an MRI which was done at another private provider, paid for by public health.
I went back to the private doctor and paid for a non-surgical treatment, which wasn't available on public health.
If that doesn't work, later I can opt for surgery, paid for by public health.
And even more importantly: There is one system that tracks all diagnoses, treatment, medication etc used by both public and private healthcare providers, so medical history is available instantly to everyone.
Within 5 minutes of searching I found a PT time with INR test for $24 [0]. Add in the testing fee and it's probably around $30.
[0] https://www.ultalabtests.com/test/prothrombin-time-with-inr-...
This won’t work too well for most stuff. They don’t have to treat anything you present with, and don’t have to fully treat even e.g. a heart attack. They just have to stabilize you. So they can turn you away under most medical circumstances. Like you’re not going to get free chemo or (non-emergency) prenatal care or what have you. They also can triage you into the “maybe in twelve hours… maybe” group until you go away if you don’t seem like you’re dying, or likely to pay.
It makes sense - the largest payer should get the best price. But it doesn’t make sense because it’s not really a market.
We’d have much better outcomes with a Medicare for all model, and then private insurance could actually be priced with an insurance model and be used as a fringe benefit again.
Making a statement that most poor people in America can’t get epi-pens is false. Most poor people can for free.
Teflon does not get a free pass. It is a toxin. The last I recall, it causes brain damage in children. There is a reason why sane people avoid nonstick cookware.
Here we go again with the PFAS. It is the stuff to prefer the least, not the most.
> I'm getting D3 and A from multivitamins
That fails completely because they almost always don't have softgel oil-dissolve forms or the right dose at all. They're generally very far from it. It is exactly what leads to the autoimmune issue of dry eyes in the first place.
For me, I find that one Dramamine I (dimenhydrinate) pill is very effective at preventing motion sickness, but it will put me to sleep quite reliably a couple hours later. Two pills and I can play Unreal Tournament 2004 until I'm too tired to sit up. I'd be quite concerned though with 3 or 4 pills about hallucinations -- and from my understanding, the hallucinations you get on dimenhydrinate are not good.
Dramamine II (aka Less Drowsy), which is meclizine, is a little less effective but usually adequate, but still reliably makes me really sleepy the rest of the day.
Kwells (hycosine) is the least effective overall for me, but I can take a little more if I need to, and it does not make me drowsy at all. I would take original dramamine every time based on effectiveness if not for the drowsy part.
Not an exhaustive list, just asked AI and quickly checked it's output with google.
There are 26 million uninsured in the US and deductibles also exist for everyone so this is just blatantly false
A. Absorbed into your body forever.
B. Becomes a part of the water cycle.
C. Is broken down.
And even choice A eventually becomes choice B, ideally after significant time though.
PFOA and PFOS have 8-member fluorinated chains. And they are dangerous, with clear dose-dependent effects.
PFHO has a 6-member fluorinated chain, and it has no known toxic effects.
> Even so, they all accumulate in the environment.
So does silicon oxide. Or a lot of other "terminal" compounds. The questions that need to be asked are:
1. Are they dangerous by themselves?
2. Do they bioaccumulate?
3. Do they stay mobile in the environment (i.e. don't get sequestered)?
In case of PFHO, it's not dangerous. It does not bioaccumulate because of its poor absorption. And it's also not mobile.
> The last I recall, it causes brain damage in children.
No, it doesn't.
> That fails completely because they almost always don't have softgel oil-dissolve forms or the right dose at all
I tried tons of forms. My current ones are gel-filled capsules. Rather large ones, at that.
Sorry, but there's a huge amount of scholarly literature on this question. I've read tons of it over the years, and there is NO magical supplement that does anything but mildly improve the situation.
And people put asbestos on their christmas trees back in the day - I don't think "obvious harm" is a high enough standard.
You are in no way smart enough to understand and consider all the pathways, uptake mechanisms, and consequences that are affected by the PFAS compound across all of biological life. Knowing just one or two over just a few years does not make you competent in it or qualified to make a broad safety comment.
You also can't find anybody in the world without traces of lead, arsenic, uranium, radium, and other chemical elements in their blood.
> Why cant you just use theratears?
Because they don't work.
Yes, they do help a bit. No, they don't help a lot. The study you cited find only a weak effect on some endpoints.
Same for fish oil and various omega-3 acids. The effects are either weak or in some cases non-existent ( https://www.nejm.org/doi/full/10.1056/NEJMoa1709691 ).
Meanwhile, Restasis (cyclosporine A) (or a generic) works well, and doesn't have to be applied all day long, just two or three times a day. It does burn the eye initially, but it's not harmful, and the burning goes slowly away over time. It does take a few months to start working.