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How You Receive Your Treatment Affects You Financially

How You Receive Your Treatment Affects You Financially

We know that RA drugs are expensive, but did you know that how you receive your treatment (pill, injection, or infusion) can affect you financially? As we enter the crazy season of open enrollment for both private/group insurance plans and Medicare, this can be important as we make selections for next year’s healthcare coverage. I, personally am in a really weird place where this is a huge quandary in my life at the moment.

Differences in coverage based on method of administration

First, a disclaimer that insurance plans vary. However, as a general rule, medications that are self-administered by the patient (such as pills or injections) are covered by the drug/pharmacy portion of the healthcare plan. This is true of most commercial insurance coverage as well as Medicare Part D. On the other hand, medications that are administered by a health care professional at a facility (such as infusions that are given at a hospital or infusion center) are generally covered by the medical/major medical portion by both commercial insurance policies and Medicare.

What is a formulary?

In the first instance, where the patient takes the pill or does the injection, the medication must be on the approved prescription list (or formulary) which also determines how much insurance coverage is provided. Tier 1 drugs, which are often generic versions of common drugs, have the least-expensive copays. RA biologics usually fall into the highest tier classification (if they are on the approved list at all). This means there are often restrictions associated with the medication (like pre-approvals) and that only a portion of the drug may be paid for by the insurance company. This can mean expensive copays for every treatment. Fortunately, many commercial/group policies have a maximum out-of-pocket that, when reached, will then cover more or all of the cost of the medication. 

Infusions, on the other hand, are covered by the medical (vs. the pharmacy) benefits. This means that once the policy’s deductible is met, the policy covers a set percentage of the treatment with the patient paying the rest. Depending on the policy this can be a split of 70/30, 80/20, or even 90/10. In my case, I am on Medicare which pays 80% of the treatment, but I also have a Medicare supplement policy that pays my 20%, so my infusions are zero cost out of my pocket. 

So this is my quandary.

 

I’m doing really well on a treatment that is given by infusion but I have really lousy veins. For the last two infusion cycles, the infusion nurses haven’t been able to start the IV. (Believe me, they’ve tried. Once they stuck me eight different times.) I’m lucky that my medication comes in both an injectable form as well as the IV, so my rheumatologist has provided me with some injectable samples in the interim. The simple fact of the matter is that I can’t permanently switch to the injectable because I can’t afford it. The per-injection cost under my Medicare Part D is almost $6000 compared to $0 for the infusion. And some of the great patient assistance programs from the pharma companies are not available to people on Medicare or other government health plans.  

We are exploring options and my rheumatologist is looking at all the angles to make this work out. I may eventually have to get a port installed, which is not my favorite idea. But then again, I’m on a treatment that works for me and I’m not really willing to switch for a non-medical reason. 

The unfortunate truth is that many of us have to make treatment changes for financial, i.e., non-medical reasons. But understanding how your healthcare policy covers your treatment, either under the drug/pharmacy benefits or under the medical benefits, is a giant step in helping you make appropriate decisions both from both a medical and a financial standpoint.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • rockcandi
    2 years ago

    Carla, thank you for posting this article. I understand better now why my rheumy made her most recent decision to start infusions if my new current pill form doesn’t help. She doesn’t think it will but we decided it was worth a try. I’ll have to have my husband miss work once a month to drive me to and from infusion clinic at rheumys hospital over an hour away from home if we must do infusions. I’m more than willing though if it will work. Anyway, what you said about meds not being on Medicare’s Part D formulary is exactly what just happened to me. I was taking Actemra injections at home once a week for 6 months and they were helping quite a bit. First med to help so much since Enbrel 3 years before that I had to stop due to it was causing my Lupus to flare. Then at the beginning of this year my prescription insurance took Actemra off their formulary. Rheumy appealed for me as I couldn’t replace Actemra with Humira like insurance suggested. They denied her appeal. So we started Xeljanz this week, which was the other med insurance suggested, even though like I said rheumy isn’t confident at all that it’ll work. If it doesn’t help at all or enough for her standards for me in 6 weeks then we will begin infusions. She didn’t say so but it must be bc of what you said about Medicare paying some or all for infusions. I hope and pray for you that you and your rheumy are able to work it out and you’re able to continue med that is helping you.

  • Lawrence 'rick' Phillips moderator
    2 years ago

    I wish you the very best in this decision Carla.

  • CharJ
    2 years ago

    Have you discussed the possibility of using a mid line or PIC line for ongoing infusions? I had a number of patients in home care using this method when they had multiple IV drugs over a prolonged period. These are generally placed by specially trained staff in hospitals and in some physicians offices if they give alot of infusions.

  • Carla Kienast author
    2 years ago

    Char: Thanks for the suggestion and it’s on the drawing board as a possibility. Both my doctor and I hate to do this as I only have an infusion every six weeks, but I will go that route to stay on treatment if I need to. We’re going to try an interim step of switching infusion providers to see if their technicians are a bit more skilled. I have had techs start an IV on the very first try so both my doctor and I are frustrated that the current infusion folks can’t seem to come close.

  • Sneed
    2 years ago

    If you’re using pills it’s worth it to check out prices at the legitimate Canadian pharmacies. The legitimate ones will require a real prescription. The ones that do not are a crapshoot and to be avoided. My hydroxychloroquine is about $350 for 200 in the states and $86 from Canada. My insurance does not cover it so that’s a big deal. I’ve been buying from a Canadian pharmacy for years and the quality is the same as here.

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