“Hi, this is your pharmacist. I just want to let you know that the co-pay for that prescription you dropped off is $400. Do you still want the prescription filled?”
[Sure, why not. I just won’t eat for the next month or so.]
***
That was an actual call from my pharmacist after my health insurance company revised its drug formulary. Asacol HD, which I need for my ulcerative colitis, jumped from a $50 a month co-pay to the $400 a month co-pay noted above. My insurance prescription plan is three tiers – $15 for the first tier, $50 for the second tier, and 50% of the manufacturer’s price for the third tier. The third tier is generally reserved for experimental and/or non-generic drugs.
There is no generic equivalent for Asacol HD, and it used to be that if there was no generic equivalent, a drug was dropped into the middle tier on my prescription plan, but now it doesn’t matter. If it is a brand name drug, it’s top tier. Period. The insurance company doesn’t care if it is the ONLY drug that’s working for a patient’s particular condition.
Well, I don’t know about anyone else, but I can’t afford $400 a month for one drug. I had to call my GI specialist and beg him to find something cheaper for me. God bless the man, he was able to prescribe a drug with a $15 co-pay. It doesn’t work quite as well as the Asacol HD, but it’s better than nothing.
Bear in mind that these drug co-pays are on top of the premiums paid for the insurance (about $12,000 a year) and the deductible ($5,000 a year). Thank heavens my company pays the premiums and the deductible for me as part of my salary package. But I’m on my own for the prescriptions.
Who’s to blame for these outrageous costs? Do the drugs really cost that much to manufacture, or are the pharmaceutical companies just greedy? Is it the fault of the insurance companies, who want to keep as much profit as possible, thereby refusing to pay for necessary medications for their insureds? Is it my fault because I wasn’t born rich? Or married rich? Is it all of the above?
I can’t answer those questions. I can only hope that my insurer doesn’t suddenly refuse to cover my Remicade treatments, because those carry a co-pay of $2,300 a month. A funeral would be cheaper.
Unfortunately, retirement is totally out of the picture, at least for now. Sure, I could possibly take early retirement and squeak by on Social Security if I worked a part-time job, but there then would be the matter of carrying my own insurance costs until I become eligible for Medicare in a few years. I have no interest in changing my diet to cat food so that I can have enough money to pay for medical insurance.
Anyone else want to chime in on this subject? Are you also tired of being gouged by the drug companies and insurance carriers?
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I love to hear from my readers. You may comment on this post, comment on my Facebook page, or email me at cordeliasmom2012@yahoo.com
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Images by: Chris Potter (http://www.ccPixs.com) and Monceau, respectively
Cordelia's Mom, Still 
My advice would be to invest in pharmaceutical companies – you’re sure to build your net worth. Especially companies that sell anti-depressants. You happen to have ailments that are uncommon CM (as my doctor says, I’m special), and there is no worse place to be. The pharmaceutical companies spend literally billions developing some medications and have to get that back from the users – so the fewer the users, the higher the cost. It actually only costs pennies or low dollars to manufacture these medications- it is the dvelopment cost that is horrendous. The problem is, of course, that we have no idea how much is actually spent – that’s company confidential – and the full price is charged until the patent runs out. Meaning they could easily be recouping their costs many times over – there is no way to know.
If you could find an alternate system for drug development CM, you could make yourself a pretty penny. The same actually applies to oil companies as well. They spend billions in finding and developing oil fields without which we would have no oil. However, they just keep charging us long after the cost is covered. They say it is for future exploration, but how much they use for that is totally up to them. When you play with billions a few hundred million one way or the other is a rounding error.
I can sure empathize with your predicament.CM. WE have similar issues here in Canada because our health care system does not cover prescriptions. I wish you the best of luck.
Great Post CM. Thank You.
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Thanks, Paul. I’ll be sure to invest in drug development as soon as I free up all that money I’m using to fund my current medical bills – it may be awhile.
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I hear ya. I know the feeling.I’m on a fixed disability income. I invest in bread, peanut butter and beans not stocks.
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Oy. I have Crohn’s and am on Remicade too. I spend approximately 1/2 of my salary on insurance, but at least it covers most of my drug costs. I have also been considering looking at coverage for next year under Obamacare (which I support) but I will look closely at drug co-pays.
I think it is complicated and part of EVERY industry’s tendency to squeeze every last dime out of us. Yay de-regulation.
You might want to check around to different pharmacies to find out what the copay will be at each of them. Distributors market drugs differently to different companies, and you might be able to get the same drug at a different pharmacy chain for much less. But it still sucks.
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Thanks for the comment, Elyse. Unfortunately, the co-pays are tied to my insurance, not to the pharmacies – it makes no difference which store I go to. My co-pays are especially high because I work for a company with less than 20 employees. I understand all that, but I still don’t think it’s fair to working-class people who are legitimately ill, but not ill enough to qualify for disability benefits.
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You might also try contacting the drug manufacturer. I know that Janssen has a program to help folks pay for Remicade — Maybe the maker of Asacol does too. It doesn’t hurt to ask.
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Full disclosure — I do drug research for a living. I looked up Asocol and they do offer an assistance/ partial reimbursement program — it may not be enough to help you though.
http://www.asacolhd.com/savings.aspx
Still, it would be better if they would just make the prices affordable …
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Yes, they do, and I had one of their discount cards, but what they offer is $50 off whatever the co-pay is – in this case, it would bring the co-pay down to only $350 a month.
I really appreciate you taking the time to do that research for me. It means a lot when readers show they care.
And I’m Ok, the cheaper medicine (balsalazide disodium) that was prescribed does seem to be working now that I’ve been on it awhile, and I’m not on a low-salt diet so I don’t have to worry about the added salt.
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No problem! I’ve had GI problems for 40+ years. We need all the help we can get!
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It may be worthwhile for you to appeal the decision of your insurance company to classify the drug you have been taking as a third-tier drug, especially if there is no generic equivalent. Our insurance plan also has a 3-tier Rx plan and one of my associates is taking a prescription that, like yours, has no generic equivalent. When it was classified in the top tier, he appealed it and got the insurance carrier reconsider and to cover it at the next lower tier. It might be worth giving it a shot. What’s the worst that can happen?
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Never thought of that. It could work. Thanks.
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I actually did a post on this on my site if you haven’t seen it already. From a physician’s standpoint, it is maddening. I used to be able to appeal decisions like this for patients but this year especially, that has become virtually impossible. “Prior Authorization” has become a joke and now many meds are just flat out “not covered under any circumstance”.
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I’ve seen some of my doctors grow angry when I had to explain that insurance wouldn’t cover this or that. Although, to be fair, my colon-rectal surgeon was very happy that under Obamacare, the hospital couldn’t force my discharge so long as the doctors felt I needed to be hospitalized. The hospital wanted to discharge me in less than 24 hours, but the doctors (all 3 of them) kept me in for 10 days. Small win for the doctors.
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That IS cool! Though I don’t know how the hospital gets to decide that. Medicare is a problem for length of stay sometimes. Insurance companies can sometimes deny coverage beyond what they deem necessary. So sometimes I would get pressure to DC someone if the hospital wouldn’t get paid. It has been five years since I have practiced inpatient medicine, though; so things may be different now.
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Bear in mind that I was pretty out of it at that point, but I believe the insurance came into play somehow due to whatever negotiated rates there were between the hospital and the insurance company. I wasn’t getting a lot of expensive tests since we already knew what the problem was, I was basically just lying around waiting for the IV fluids and PIC line to do their jobs. The hospital “patient rep” suggested home care, but it was explained that was not feasible at my house due to no one being available to watch me, coupled with two somewhat aggressive dogs who might not take kindly to strangers coming in, thereby adding to my stress level. My surgeon, my GI specialist, and my primary all agreed that until I stopped bleeding and could keep some food down, it was safer to keep me in the hospital. I believe it was the right decision because I likely would have been back in immediately if I was sent home too early. (I did miss those somewhat aggressive dogs, though, and I sure as hell missed my own bed!). Even once I was home, it took another two weeks before I could really resume my normal pre-illness routine. I don’t ever want to go through it again.
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Yeah, that was case management. And it was due to an unholy alliance between your hospital and your insurance company. That being said, no case management person is going to throw a patient out on their ear against medical advice. Bad for PR and bad for liability. 🙂
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Yeah, I remember that my colon-rectal surgeon actually smiled when I told him what had happened, and he said, “They can’t make you leave until *I* say you’re ready to leave.” I think I fell in love with that guy at that point – at least, I believe knowing my doctors were backing me up might have made my recovery a little quicker.
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🙂
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I feel for you, and understand what you’re going through. My wife has similar problems. I had to call MasterCard from my pharmacy one day, because the total bill for five meds was over the $1000 daily limit. The rep thought I was buying electronics.
While my auto-parts employer shut down, and forced me to leave before a 20-year retirement date, the Big Three guaranteed my retirement pay and a great medical plan. I wish you luck, both with the GI problem, and with the payment situation. 🙂
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$1000 for meds? Wow. There’s really no reason why the average consumer should have to pay that much out-of-pocket in an attempt to stay healthy.
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Reblogged this on Cordelia's Mom, Still and commented:
As I face loss of my job, and loss of my insurance, I have to reconsider whether or not I can afford my much-needed Remicade treatments. On top of everything else, I’ve already paid in $2500 of my $5000 annual out-of-pocket expenses for this year, but if I have to change to a different plan (even if it’s with the same insurance company), I have to start back at 0! Why did Obamacare never take into account those who need to change plans in the middle of the year? Is it fair for me to have to pay $7,500 this year, while everyone else on a similar plan pays $5,000? Ugh!
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I heard about this a while ago, I don’t know if it still exists, or if it can help you stay on Remicade. It is a way to get less costly infusions: https://www.vitalssmartshopper.com/Login?ReturnUrl=%2F
Total disclosure — I didn’t try this. My infusions cost $50 every 6 weeks and I didn’t want to mess with success. (And I’m a really hard stick)
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How on earth do you get infusions for $50 every 6 weeks? My Remicade is every 8 weeks with a co-pay of $850-895! I’ll check out that website.
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That is just my co-pay. I will stop griping! Also, the sponsors have programs to pay up to a certain amount for a few years. Look at the Janssen website for remistart program. Especially if it is short term!
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I will. Thanks, Elyse.
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Here’s the website: http://www.remicade.com/crohns-disease/co-pay-support
There are catches — and you will have to have some form of insurance to qualify (which to me sounds counterintuitive) Good luck with it.
This is my biggest fear — not being able to get my medicine! Don’t they understand the cost to society of people who don’t get it? Jeez!
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You’re a life saver, Elyse, possibly literally. That link is going to allow me to continue my treatments, no matter what happens with my job search. I don’t know why I never heard about it before – but then, my employer has been paying my co-pays, so it wasn’t an issue.
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I’m so glad I saw this post! I have been paying less attention to logging lately!
And you never need something like this until you need it!
Good luck –I know you’ll have a new job before too long. But it’s a nice comfort to know there is help.
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MOSTLY, Medicare is better about this stuff, but not always. MEDICAID, which is the state (not Federal) version of this covers everything. You just have to be poor enough to get it, but if you can, it’s the absolutely BEST insurance anywhere. Ironic, isn’t it? Most of us are too poor to pay the freight on these inflated drug prices, but not nearly poor enough to get any help.
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My brother, who’s been unemployed for year (laid off at the age of 55!), just got onto Medicaid. Once I’m unemployed, or seriously under-employed, I’ll check it out, too. There must be away around this whole thing.
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The Affordable Healthcare is why we are still working (much older than 65.)
Medicare is expensive, too – never have we paid so much for insurance and had poorer coverage…it gets worse every year. Infuriating.
More and more docs are finding they cannot afford to treat medicare patients. Docs are trying very hard to care for their patients -to get them the treatments and meds they must have – it means constant battles on the phone between docs and insurance clerks who want to tell them how to treat patients cost effectively (not what treatment is best for patient) and what drugs docs can prescribe. You are lucky if the hopsital system will work with the doc to get you what you need. They both have to learn how to work the healthcare mandates to take care of you.
If you are poor and have nothing or young and healthy – the affordable healthcare act is great…the rest of us are paying in more ways than one
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Amen.
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Insurance is the devil and big pharma is greedy. That’s where I stand. My husband took a new job because of the benefits. Seriously. It’s a longer commute, but this insurance, all of it, is outstanding. Dental, Health, vision — all much much cheaper co-pays, lower deductibles, same premiums give or take $5-6. I hope it doesn’t seem like I’m bragging, we’re both so relieved. Moo’s nose spray used to be $152 something. You’d think it had cocaine in it, but no. Now it’s $17.
I do think the ObamaCare could do a lot better with folks in transition. But then, I want fully socialized healthcare with a single-payer system, so there’s that. Healthcare, not just sick care.
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I understand completely, Joey, and believe me, I don’t see it as bragging. The one thing that will help me is the fact that I can go onto my husband’s insurance – he works for a huge company and the premiums will be fairly low. The only drawback to that is that he has to continue to work for that company, and he’s not young, either.
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Silver lining, but yes, I understand that, too.
There’s a lot of marginal in this country, isn’t there?
People of a certain age, struggling to find jobs more than most — seems 22 and 60+ are in opposite but equally awful boats.
Too many families earning just above the line that would let them eat better.
I don’t like any of it.
What has struck a chord with us is that we live in a state without Medicaid expansion and so for most Hoosiers, the healthcare.gov isn’t cheaper at all, and if your job offers insurance…even at crazy prices…well…too bad for you.
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This is terrible and I wish you the best of luck. My mom is on 8 different prescriptions. One is also not covered due to it being too new on the market and she flat out told her doctor that she wouldn’t be paying for/taking it. He gives her samples. He is great but this system really is disgusting. Haven’t been keeping up with it, but I wonder if Congress now has to poop where they eat and swallow their own brand of “healthcare”.
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Would it really matter if they did, because they aren’t living anywhere close to ‘paycheck to paycheck’?
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True, but that 500$ that they spent on scrips means they have 500 fewer dollars to spend on other things….like prostitutes. I could hear the war in their minds…hmm i need to refill my scrip. Dang, now I can afford only 5hrs instead of 10.
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My friend’s son-in-law and grandson are both on Remicade and it costs them a ridiculous amount every month!! I think healthcare in general is a joke in our country! I think it’s disgusting and very sad that these pharma companies, and whoever else is involved, care more about the profit margin than the health of their fellow humans.. maybe they’re not human at all??
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It’s the bottom line that counts, and that’s all that matters, apparently. I don’t think Remicade really needs to cost that much, even if it is sort of a miracle cure.
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I’ll keep you in my prayers!
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