The High Cost of Living: Paying for Vital Prescriptions

The High Cost of Living: Paying for Vital Prescriptions
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prescription costs

When I quit my full-time job to focus on my freelancing career earlier this year, I gave up a steady salary. Worse, though, I also gave up all the benefits that went along with it, including a terrific PPO health insurance plan that covered my Remicade infusions entirely with no out-of-pocket cost.

When I transitioned to coverage under my husband’s high-deductible health plan (HDHP), I knew there would be some changes to my coverage. But I was unaware of how drastic the difference would be financially, especially for the cost of my only two prescriptions: my anti-rejection medication tacrolimus for my liver transplant and Remicade (infliximab) for Crohn’s.

I was first hit with sticker shock when I had to refill my prescription for tacrolimus. Under my PPO, after meeting a $50 annual deductible for prescriptions, I only had a $10 copay. With the HDHP, the cost would be more than $450 a month until my husband and I met our total plan annual deductible of $3,500. My Remicade infusion was scheduled for a few weeks later and I could possibly meet our deductible with that alone. So I decided to pay the cash price of $151 instead of claiming my prescription on insurance to save money in the meantime.

Based on past insurance claims, I knew my provider charged around $4,700 per Remicade infusion. Because the price included both the medication and the infusion service, I was unsure how my new insurance would cover the claim. I was confused by the information I found online, so I called customer service to avoid getting blindsided by having to pay anything at my appointment.

I wasn’t very confident with the insurance rep’s quote of a $70 office visit copay for the infusion, so I contacted my doctor’s billing office. The billing representative wanted to confirm her answer with her manager and told me she would have the manager call me back. The billing manager never called before my appointment, and the infusion nurses didn’t have instructions to collect payment from me. They told me not to worry until I received a bill. A couple of weeks later, I did.

Based on the $2,900+ bill, I finally understood that insurance wouldn’t cover any of the cost for the infusion until we met the deductible. Because we had already paid a portion of the deductible for the year, the infusion pushed us so far over the $3,500 amount that I only had a 10 percent copay for some of the charges.

Our health savings account (HSA) only had about $600 in it, and I immediately deposited $3,000 into it to pay for the bill. A couple of days after I made the deposit, I received a call from my doctor’s billing office. I was expecting the representative to ask for full payment, but instead she asked if I was enrolled in the Janssen CarePath program to help pay for the Remicade.

CarePath provides resources and financial assistance for patients who are prescribed one of the many Janssen medications, including Remicade and Stelera (ustekinumab), and who meet certain criteria. First of all, the patient’s healthcare provider must participate in the program. As a registered provider, doctors are assigned a care coordinator who can assist with reviewing patients’ healthcare coverage, billing and reimbursement, and coordination with specialty pharmacies and infusion centers.

Patients can then enroll in the program if they have commercial or private health insurance. Individuals receiving Medicare, Medicaid, or some other form of government-funded health programs, and those who lack any coverage are ineligible for assistance, but CarePath provides information to help them find other resources for help.

Reimbursement varies by medication, so I can only speak about my experience with Remicade. Under the program, patients pay $5 for the cost of the medication and CarePath pays the remainder with an annual maximum benefit of $20,000. Only the prescription costs are covered, so the patient is responsible for all other infusion-related costs. For me, more than 92 percent of my bill was for Remicade; thus, the savings I received was tremendous.

As an added benefit, the CarePath payment applied toward my insurance deductible. Technically, CarePath covered almost our entire deductible for 2019, saving us close to $3,000 of healthcare expenses. Savings vary depending on individual plan copays, deductibles and coinsurance payments. However, any savings is worth the 15 minutes or so it takes to enroll in the program.

I just had my second Remicade infusion under the program and am still waiting for the bill from my provider. Although I am not sure how much I will owe this time, now that I’ve met my deductible and have CarePath, I’m not worried about breaking the bank.

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