I’ve read a rant or two in the personal finance blogosphere recently and now it’s my turn! I’m infuriated at the cost of prescriptions here in the United States. My fury is a personal one and I’m going to make it my personal mission to find alternatives.
Before I begin, I should remind you all I work for a broker/third party administrator so I know a thing or two about health insurance.
I’m Violating My Own HIPAA
Okay so I’ll get personal (like I haven’t done that before – haha!) to give a backstory to my rising frustrations. When I was 23 years old I was diagnosed with Ankylosing Spondylitis (AS). My dad has it too so like father like daughter.
It’s an autoimmune disorder that results in inflammation. That inflammation is primarily in the sacroiliac joint and spin; however, it can also affect the chest, eyes, and some other joints as well.
Flare-ups are generally treated with nonsteroidal anti-inflammatory drugs (NSAIDs). Although, I’ve been treated with steroids for eye flare-ups.
So if you ever hear the term miracle drug, just think high cost. There are a series of biological medications which are made from living organisms. The Tumor Necrosis Factor-alpha (TNF -α) inhibitors are very effective at treating AS as well as slowing the progression of the disease.
Wonderful, except that miracle drug = $$$
I was prescribed Humira in the fall of 2018 as I’d been having a lot of flare-ups this past summer. I’ve been taking it since with great results.
I have a high pain tolerance but my biggest concern is the progression.
You see my father’s spine is mostly fused and while he no longer has back pain, he is crippled. That is the typical progression.
So since this is a personal finance blog let’s get into the dollars & sense of it all. Guess how much this miracle drug costs for one month’s supply? Seriously go ahead and guess. I’ll wait…
Yeah, so it costs $4,842.95. Not too high, right?? That is almost $60k per year. That is OUTRAGEOUS!!
What’s even more outrageous is the game one must play with the manufacturer and insurance companies. When I was approved by the insurance company for the drug, I was also approved for a manufacturer’s coupon. The manufacturer gives me up to $12,000 per year in coupons as long as I have private insurance.
I order the Rx, the insurance company applies the coupon, and I only pay $5. Lovely, right? Well, there’s one problem and that is someone is paying for it…
How This Affects the Insurance
The coupons will cover you until you meet your insurance deductible. Good deal, right? There are two issues with this and the latter one is what concerns me most.
Firstly, insurance companies are doing something called true payment processing. They will only give members deductible credit if they actually pay for the drug themselves. Coupons don’t count towards deductibles. Fair enough.
There is a workaround, though, and it was explained to me by the manufacturer. All I had to do was pay the full cost of the drug, submit my receipts to the rebate program (manufacturer), and be reimbursed for all by $5. I tested it and it worked. Additionally, I got deductible credit for this.
The word on the street is that the insurance companies are onto this game and will be figuring out how to not give deductible credit for such episodes. This game will keep going on and on…
Not that I typically feel bad for the insurance companies, but I can see they are the ones getting the raw end of the deal here. Think about it – the manufacturer gives you a coupon and then sticks the insurance company to cover this drug for the rest of the year.
Affordable Care Act
When the Affordable Care Act was passed, small groups (under 50) were forced to go on community-rated plans. Exceptions were made when President Obama said, “if you like your current plan, you can keep it.” Insurance companies allowed groups to stay on their old plan and called it grandmothering.
However, any new plans had to be community rated which meant the policy could not be rated based on risk. Isn’t that how insurance works??? Anyway, they could only rate groups on the following:
- Age of members
- Service industry code
- Zip codes
- Smoking status
Insurance companies had no idea what kind of risk they were getting so they raised their rates. The Affordable Care Act turned out to not be so affordable.
When rules are made, people find loopholes. Insurance companies found creative ways, at least here in Ohio, to underwrite risk again. Multiple Employee Welfare Arrangement (MEWAs) and level funded plans emerged in the market place and were approved by the Ohio Department of Insurance.
Don’t worry about exactly what these plans are (or look them up if you must) but just know that it’s a way for insurance companies to underwrite risk again.
With the emergence of these plans, competitive rates came back around!!
My Companies Insurance Plan
The small company I work for has a medically underwritten MEWA plan with attractive rates. We bought a high deductible plan ($6,550) but some of that is funded by my employer. I’m on the hook for the first $1,350.
I actually met my full deductible ($6,550) early on this year because of a little medical mishap. That being said, I can fill Humira all year long and pay nothing. What is so bad about that?
I will wreck our policy and cause mine & my colleague’s premium rates to drastically increase next year.
My single premium for this policy is $361.84 (which is paid 100% by my company). Let’s see how this shakes out for the insurance company.
Bottom line – the insurance company ends up paying out way more than it takes in. I know that this is what insurance is for but this is the curse of me knowing too much. I don’t want to wreck our policy.
My conundrum is that I want to continue to take this drug and preserve my future. What’s a girl to do?
Here is where I get really mad about this stuff. I saw my rheumatologist this week and told him I need an alternative. He shared this article with me from the New York Times:
That title basically sums up how I feel. In case you don’t feel like reading it (though you should it’s short), let me share a little paragraph from it:
“Top drugs, no matter how profitable to start, are routinely increased in price up to 20 percent annually in the United States. A patient could fly first class to Paris, stay at the Ritz, dine at a top Michelin restaurant, buy A one-year supply of Humira at local prices in France, fly back home and finish with enough profit to hire a registered nurse to administer the injection every two weeks.”
Um, whaaat?!? There is something very wrong here.
Additionally, we googled the average prices of Humira in the world. We found some stats from 2015 which shows South Africa as the country with the lowest costs.
This brings me to considering medical tourism. The challenge I forsee currently is that Humira needs to be refrigerated. I’m not quite sure how I’ll get past customs with a year’s supply of Humira on ice.
Anyway, I’m investigating it and my doctor encouraged me. Additionally, he joked that I needed to take him with me wherever I go. Travel reward miles anyone??
I’m going to doing some research and then my boss & I will work out some kind of arrangement. If I can figure out a way to make this work and preserve our policy, it’ll be a win/win.
I’m all about thinking outside the box so I consider this a fun little experiment.
Going to the Foundation
I realize there is an incredible amount of research behind these miracle drugs. Additionally, I recognize they need to be paid. However, with the drastic disparities in costs all over the world, I see that there is a BIG problem here in the U.S.
Before I explore medical tourism, I will approach the Humira foundation to see if I can be approved for some type of discounted program outside of my insurance. I’d like to think there is some altruism behind the creation of this drug and they’d want to help me. Furthermore, it’s in their best interest in me being a continuous customer.
We’ll see if anything turns up here. Doubtful but worth asking.
It’s incredibly frustrating to find a solution for a condition but then to be faced with the outrageousness of it all. I’m writing this as I imagine there are others who’ve been faced with high-cost prescriptions and similar frustrations.
My doctor said something that really stood out to me – the most important thing is my health. He said everything else really doesn’t matter if we don’t have our health. How can I argue that?
I’m going to embark on this experiment but if nothing really pans out maybe I’ll be forced to just take it as it is. However, it cannot hurt to try. Things don’t really change if we never challenge them, right? I’ll share my progress and results with you right here on my blog so stay tuned.
Have you experienced outrageous costs with your healthcare? Would you be willing to consider medical tourism?