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.