Cost of RA medicine

I have shared my story and now have a question. I am currently on Methotrexate and my co-pay is $10 a month which is manageable. My Rheumatologist has recommended Biologics and since I will go on Medicare in January I have began researching Medicare Supplement Plans. I am being told that Humira, Enbrel and even Xeljanz are Tier 5 drugs and my cost will be close to $5,000 or more for the year. No way can I pay this amount. Does anyone have any suggestions or alternatives? I am so disappointed that people who suffer with chronic diseases and pain are subjected to these outrageous prices!

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  • Dave
    2 years ago

    I retired and went on Medicare this year and at the time I was doing self injections on Humira. With my employer provided insurance and the copay card from the drug company my cost was $5 for a three month’s supply. When I went on Medicare the cost was astronomical. The biologics that are administered by infusion are covered under Medicare part B and I have a supplement plan “G” that covers the 20% that Medicare doesn’t pay. The cost for me is zero. I would ask my Rheumatologist about that alternative. Plan “G” supplement policies have a one time per year deductible of under $150 and after that they pay 100% of what Medicare plan “B” does not (on medicare approved costs) and the premiums for them are affordable. Hope that this helps. (I noticed that you were from NC, so am I!) Dave

  • Pwilcox author
    2 years ago

    Dave, thank you so much. I have done exactly what you have said. After 40+ years of working for the same company, I retired in 2014 and unfortunately the company I worked for cut all retiree benefits. I carried Cobra for 18 months and then had to be on Obamacare for 2016. Another story, but Healthcare Reform is not affordable for many of us. They would not pay any of the infusions until I reached $6,700 out of pocket in addition to paying my high premium. Thankfully, I will be on Medicare beginning January 2017. I talked to several people including my Doctor’s office and they told me the same thing you did. I have signed up for Plan G and should be able to begin transfusions in January. No one wants to get ‘older’ but with our healthcare system in the United States I am glad to reach the age where I can get the transfusions I need and not go bankrupt. Thank you so much! Another note: I am sorry you have RA, it seems to strike women more than men. I hope you are coping well without too much pain.

  • Sneed
    2 years ago

    I don’t know if it would work for the meds you mention but my dmard has been hydroxychloroquine, and yes, I’m lucky it works. I priced it at several U.S. sources, Walmart & Kroger, and the cost for a two month supply was about $350. I looked into Canadian sources and have been paying about $60 for the same amount ever since. There is no insurance reimbursement but it still saves a bunch. There are several sources in Canada but I ended up with canadadrugstop.com and have been very satisfied by my dealings with them.

  • melody123
    2 years ago

    I checked into Kaiser plans. Since money was an issue I could not afford the medigap coverage of an extra 186/mo. I have Medicare and get the Orencia intravenous free at the Drs office which is what I need. I do not have the ability for enbrel shots or the new pill for RA [forget the name] as the copays are expensive I also have no need of surgery as the Orencia is protecting my joints. I would pay 200$ a day if I need hospitalization Well I hope this helps

  • Connie Rifenburg
    2 years ago

    well, this is a good time to tell you about medigap. i turned 65 in april-2016. i have tried to use 3 different biologics and the one that worked was orencia. when these drugs are new the company has all kinds of programs with copays…BUT you cant use them on medicare advantage for all the reasons you stated. i had to go off orencia because with aetna, my co pay was $1700.00 per month for the infusion.

    i finally met a neighbor/friend who knew the ins/outs of medicare/medigap policies. it was the best thing to happen to me since i’ve been disabled! i live in florida and the medigap plan F is what my doctors call the “cadillac of insurance”. i pay $186.10/mo and everything is covered 100%! everything! no deductibles, no co-pays for anything!. if you sign up for supplement F as soon as you turn 65, they can NOT make you pay a higher price for having a chronic disease. but if you wait and go with a medicare advantage plan and then try to get a medigap policy, the insurer can deny or raise your rate due to the cost of a chronic disease. you have a one time chance to sign up without a physical when you turn 65.

    i looked into medigap from age 57 when i first went on medicare due to disability…the same exact medigap policy was over $600/mo plus the medicare A B which they automatically take out of your social security ck – $104.90? plus you must buy a part D prescription plan too.

    i added up what i was spending for dr. co-pays and co-insurance for things like tests and xrays, etc, and it was always over $5,000. a year (just in co-pays) on a good year using a medicare advantage plan. then if i was hospitalized or went to the ER, or even had to have an ambulance, the co- pays and the possibility of an out of network dr. was a nightmare to say the least.

    i have RA, but i also have OA, fibromyalga, glaucoma,and wet macular degeneration which require me to go to the eye dr for an injection into my eye every month probably for the rest of my life. @$40/a specialist dr visit and the cost of the medications for the injection/infusion, if i had a flare where i visited more than once a month, i was not able to afford the basic care i needed.

    since april of this year, i have had two ambulance rides to ER, one hospital stay of 2 days,2 ER stays with ct-scans, xrays, blood and urine cultures and testing for kidney stones, i had bi weekly chiropractic adjustments to help with horrible muscle spasms in my neck and back, surgery to remove a bone in my hand & carpal tunnel surgery, knee injections at my RA dr office 1-wk for 5 wks to try to keep me from knee replacement, 4 visits to my primary dr, flu shot, pneumonia shot, injections into my back and shoulder with steroids, and i have not paid one penny over my monthly premium!!

    my biologic is ‘free’ if i get it at the dr office and that alone is $1700/mo copay savings!! so this is what i pay every month in premiums: $104.90 medicare A&B + $186.10 medigap plan F (mine is through AARP), and $35.00 Part D prescription coverage plus the cost of my pharmacy meds which average about $60-100/every 90 days. no surprise costs because everything is covered at 100%.

    everyone’s care is different, but if you have very many dr. visits or a high deductible plus co-pays i would almost promise you will save money. in fact, the medigap plan F
    only costs $144/mo in ohio but they are required to cover everything that my $186.10 premium covers for the same plan in Florida.

    i looked at so many plans and compared them all and especially since i have had so many issues, this has been a life saver! if you don’t have many medications, there are plan D plans for $17/mo @walmart or sams club, but they have a deductible of $300-400 first on some meds, the one i pay $35/mo has NO deductible and most of my meds are $1.00 – $7.00 for 1 month supply except for the brand name narcotic.

    i can’t tell you what a stress saver it is to know exactly what i will pay every month for medical costs and no worries about emergencies or hospitalizations, operations, and no out of network issues since any dr that takes medicare will take medigap – in fact they love you for having such good insurance and will order tests you may need but normally don’t order because of the cost.

    if you have any questions i would gladly try to answer them since i spent months looking for the best coverage after age 65, plus had someone in the business who helped advise me.

    you can go on line at medicare.gov and get the details about the cost in your state for medigap Plan F. until america catches up with the rest of the world in our medical care, this is the answer for me for sure.

    please excuse all my lower case typing since i’m recovering from the hand surgery for the next 6-8 wks i can only use one hand to type.

    best of luck with your medicare choices – it can be so very confusing!
    sincerely,
    connie

  • LasaterLK67
    2 years ago

    Connie, can you please tell me what perscription plan D you are on. I am on Express Scripts part D and my premium is $60 per month plus I still have a deductible of 350.00. I don’t have a medigap as I did not plan on retiring when I did. It was past my 65 birthday. I started getting flares and couldn’t go to work on some days so I knew it was time. I did sign for Social Security but that was in April. My 65th birthday was in Feb. I will be signing up for the Medigap the enrollment period. Thanks for any answers you can give me.

  • Pwilcox author
    2 years ago

    Hi Connie, Much love from North Carolina! I cannot tell you how very much I appreciate you answering my question – and taking the time to type with one hand brought tears to my eyes. This was God Sent for sure. I just read your reply to my husband and he agrees with me. We have an apt. this afternoon to discuss my Medicare Supplement. I printed out your reply and am taking it with me!

    In case you have not read my story, I had a great job with the same employer for 40+ years when I was diagnosed with breast cancer. It was caught early and all I needed was radiaton – BUT – the radiation triggered RA. It took 18 months of excruciating pain going from Dr. to Dr. (and unneeded shoulder replacement in there, another story) to get a diagnosis. During that time I gave up a great job and Insurance benefits because I could not work with the pain. Unfortunately, my employer cut out all retiree benefits. I carried COBRA for 18 months and had to go on Obamacare in 2016. It has been a nightmare this year. I have had no ER visits, no hospital stays, yet my premium and out of pockte costs are already at $10,000 for this year! I wish someone would interview me about HealthCare Reform, I would love to tell them how horrible it is for the average working class American who has worked all their lives to have something.

    I am thankful to be turning 65 and going on Medicare. Our budget could not stand another year of Obamacare. My Rheumatologist has agreed to wait until January to put me on Biologics because I could not afford it right now.

    Your information has helped me more than you know. I am so sorry for what you are going through and grateful you took time to reach out. I will keep you in my prayers.

    Thank you again,

    Phyllis
    supplement

  • thegallopinggrandma
    2 years ago

    I am very lucky as I live in SW Ireland. Here the government pay for my Humira and Methotrexate injections ! Doesn’t cost me a penny, although I have to pay for other medications that go along with it. I’ve been on Humira for over 10 years and it is like magic juice !

  • Pwilcox author
    2 years ago

    That is awesome. Our system in the United States is at a crisis. These Biologics are so expensive. If you are not insured by an employer you are out of luck as deductibles can run as high as $10,000 before you get any payment. Maybe I will move to Ireland! Thank you for responding.

  • Richard Faust moderator
    2 years ago

    Thanks for writing Pwilcox. The expense of medication is one of the most serious treatment issues in the RA community. In regards to the biologics, most of the companies have co-pay assistance/support programs. This article from one of our contributors touches on this issue: https://rheumatoidarthritis.net/living/biologic-accessible-affordable/.

    My wife, Kelly Mack (a contributor here), was on Enbrel and is being switched to Humira and signed up for such programs for each medication. Ask your rheumatologist about these programs. You can also find information on the medication Web sites.

    Keep us posted on how you are doing. Best, Richard (RheumatoidArthritis.net Team)

  • Pwilcox author
    2 years ago

    Thank you Richard. I have had no problem with Methotrexate as it it a $10 co-pay every month. When my Dr. suggested Biologics which are Tier 5 drugs, I called my current Insurance Carrier and could not believe it when they told me how much I would have to pay. I will be going on Medicare in January and my understanding is that most of these companies do not work with Medicare. I am being told that a Medicare supplement should cover the costs and I am hoping that is the case. I will find out this week hopefully if the medication will be covered under a supplement. If not, I will talk to my Rheumatologist about these programs. Thanks for your response.

  • Richard Faust moderator
    2 years ago

    Thanks for writing Pwilcox. The expense of medication is one of the most serious treatment issues in the RA community. In regards to the biologics, most of the companies have co-pay assistance/support programs. This article from one of our contributors touches on this issue: https://rheumatoidarthritis.net/living/biologic-accessible-affordable/.

    My wife, Kelly Mack (a contributor here), was on Enbrel and is being switched to Humira and signed up for such programs for each medication. Ask your rheumatologist about these programs. You can also find information on the medication Web sites.

    Keep us posted on how you are doing. Best, Richard (RheumatoidArthritis.net Team)

  • Lauren Tucker moderator
    2 years ago

    Pwilcox,

    Thanks so much for reaching out to us and asking this question. While we understand how challenging it can be to switch treatment plans, we also know the financial burden it puts on some of us living with RA.

    The community and other moderators may offer you some support with this question however, I thought this article “6 assistance programs.” would be helpful. https://rheumatoidarthritis.net/living/six-assistance-programs/

    We also encourage you to talk to your rheumatologist about the affordability of your medications and assisting you in finding one that is covered.

    Thanks for being part of our community. Please let us know how you make out.
    Best,
    Lauren (Community Manager RheumatoidArthritis.net)

  • Connie Rifenburg
    2 years ago

    Phyllis and 274rh3i: I am just reading your responses from Oct. I ended up going into the hospital for a week with a high fever. (I told the story in another area) but I wanted to find out Phyllis, if you were able to get a Part F or G plan to cover your 20%? I didn’t say before, but I did look at the K plan which was similar to the F, but cost less monthly and you did have to pay “some” of your copays, etc. I calculated that it was better for me to pay a little higher monthly on the F Plan supplement than to worry about what was paid and wasn’t. With F plan EVERYTHING is paid.

    274rh3i: as far as your question about Part D medication plan, I am changing this year to AARP Walgreen’s plan which is only $22.50/per month and covers all my medications that are tier 1 @ 2, but has a $400/ded. on Tier 3,4,5. The estimate they gave me on the AARP website, after I put in all my meds, showed that I would only pay about $451 per yr on this plan. I would check into it and see if it’s offered where you live. The plan I had thru Aetna this yr went up from $35 to $39/mo and each tier went up also, so that’s why
    I started looking for another plan. I’m staying with the AARP Plan F Supplement as it has been a lifesaver for me this yr.

    In addition to what I listed in my first post here, I had to go back into the hospital for 6 days and had all kinds of tests, catscans, xrays, even a spinal tap,during that 6 days and many extras due to a high fever of unknown origin. I have not received even one bill from that whole stay and one more ER visit for high BP after I came home from the Hosp.

    I sure hope that anyone turning 65 looks into a supplement plan if they have a chronic disease. It is how Medicare SHOULD be. Everything covered! No Worries! Less Stress!

    Sincerely,
    Connie

  • Pwilcox author
    2 years ago

    Thank you so much Lauren, this will be a good start for me. Two of my favorite words are ‘never assume’ and I ‘assumed’ that once I went on Medicare and secured a good supplement things would look up as far as cost of treatment for RA. I am heeding my words once again, ‘never assume’. Your help is much appreciated!

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