THE BURNED OVER DISTRICT

In the modern world of pharmaceutical dispensing, the price to the consumer may not be as good as he/she thinks it is. And this is the result of negotiations with manufacturers and determinations of profit levels by middlemen. The results can be shocking.

Patrik Swanljung found this out when he went to fill a prescription for a generic cholesterol drug. In May, Mr. Swanljung handed his Medicare prescription card to the pharmacist at his local Walgreens and was told that he owed $83.94 for a three-month supply.

Alarmed at that price, Mr. Swanljung went online and found Blink Health, a start-up, offering the same drug — generic Crestor — for $45.89.

It had struck a better deal than did his insurer, UnitedHealthcare. “It’s completely ridiculous,” said Mr. Swanljung, 72, who lives in Anacortes, Wash.

In an era when drug prices have ignited public outrage and insurers are requiring consumers to shoulder more of the costs, people are shocked to discover they can sometimes get better deals than their own insurers. Behind the seemingly simple act of buying a bottle of pills, a host of players — drug companies, pharmacies, insurers and pharmacy benefit managers — are taking a cut of the profits, even as consumers are left to fend for themselves, critics say.

Although there are no nationwide figures to track how often consumers could have gotten a better deal on their own, one industry expert estimated that up to 10 percent of drug transactions involve such situations. If true nationwide, that figure could total as many 400 million prescriptions a year. The system has become so complex that “there’s no chance that a consumer can figure it out without help,” said the expert, Michael Rea, chief executive of Rx Savings Solutions, whose company is paid by employers to help them lower workers’ drug costs.

Pharmacy benefit managers, the companies that deal with drug benefits on behalf of insurers, often do negotiate better prices for consumers, particularly for brand-name medications, Mr. Rea said, but that’s not necessarily true for some generic drugs. Insurers’ clients are frequently employers overseeing large numbers of workers, and the companies are focused on overall costs. So when insurers seek deals for generic drugs, they do so in batches, reaching agreements for groups of different drugs rather than getting the lowest price on every drug.

As a result of these complicated layers of negotiation — which are not made public — different insurers end up paying different prices for individual drugs. Further compounding confusion for consumers, some insurers require a set co-payment for each prescription — say, $15 or $20 — even when the insurer reimburses the pharmacy at a much cheaper rate.

Several companies have emerged to capitalize on consumer anger over the confusing variations in price. The players include not only Blink Health and its better-known competitor GoodRx, but also veteran businesses like the benefit manager Express Scripts, which recently helped to start a subsidiary aimed at cash-paying consumers. Amazon, the online behemoth, is also said to be considering whether to join the fray.

Last Sunday, CVS Health announced plans to merge with health insurer Aetna, a move that would create a corporate behemoth that many have said would have little incentive to serve the needs of regular people. Some consumers say their experience with CVS already demonstrates how easy it is to fall through the cracks. In one case, a customer whose plan was managed by CVS Caremark, the drug benefit manager, would have had to pay more for a drug through her plan at a CVS than what she ended up paying at the same store, with a coupon from GoodRx.

The wild, wild free market among the dealers with precious little consideration for the consumer. And very little the consumer can do to find the best deal.