Saturday, January 27, 2018

Co-pay assistance

   It has been a long time since I have had something cool to share. I’m actually very excited about writing this post. A few years ago the insurance program I had through Kaiser Permanente radically changed. Prior to the change I enjoyed $20 office visits $20 prescriptions and $5 injections. Cancer medications were free.  The affordable care act changed everything. Don’t get me wrong I am not bashing on Obama care. Things needed to change and they did. Some of the changes were for the better some of them were not. In my case, I was forced from the cushy HMO health plan I had enjoyed into a high deductible 80/20 plan. For most people, it’s not a bad gig. If you don’t see the doctor very often  it lowers the cost of premiums and the health plans include free check ups and preventative care. For me, it was like finding out  there was no such thing as Santa Claus. 
   On my new insurance plan the cost of prescriptions is not all that bad once the deductible has been met but January eats a huge hole in my wallet. Our new plan offers a health savings account to ease the pain but it has been hard to put a lot of money into it as my take home pay must pay the price.  They say “Necessity is the mother of all invention.” Faced with high out of pocket costs I began to explore my options. 
   Pharmaceuticals are expensive. My insurance company is billed over $9,000 a month for Zytiga. I take 4 pills a day. That equates to $75 per pill. That is more money than I earn in a day. Drug companies have patients over a barrel when it comes to our medicine. In many cases we have to take the drugs or we die. It seems unfair but as my momma use to say, “nobody ever said life is fair.”
    The cost of bringing a drug to market is enormous. Research and development is partially funded through the
Congressional Directed Medical Research Program. Funds are allocated through the
Department of Defense. In reality however this money is just a drop in the bucket. Once a drug has been developed clinical trials begin. This is where the cost of bringing drugs to market skyrockets. Pharmaceutical companies must utilize investors to cover the cost. Most investors only invest for one reason. They want to make a lot of money. Investors have 10 years to capitalize on investments once a drug has received FDA approval. After 10 years generic copies can go to market. It can be a long 10 years for the consumer. Pharmaceutical companies realize this and many of them now offer co-pay assistance. 

So how does it work?

   Well.... let’s just say it is a little different for every drug but each one shares similarities. Some medications require a financial statement proving income falls below minimum thresholds. Some do not. As I am only privy to one example, I will share my experience in hope that it will help others find their path.
   It was actually my doctors’s medical assistant who was instrumental in securing co-pay assistance for me. I cannot overstate the value in creating a strong professional relationship with the medical assistant or the R.N. I have stated in previous posts that doctors are overwhelmed. Unfortunately, they have less and less time for the patient in many cases. It is the nurses who carry the bulk of patient care. Get to know your nurse. They are a valuable resource.
   The medical assistant went online to the Janssen website to see if they offered co-pay assistance. Once she found what they offered she checked to be certain I qualified. Once qualification verification was completed she signed me up. Janssen sent the co-pay assistance coupon directly to my pharmacy. 
   Now that the pharmacy has the coupon, they first bill the insurance company. After billing the insurance company, the  pharmacy sent the residual balance to Janssen. Janssen covered all but $10 dollars of the $1560 balance. My deductible for the calendar year has now been met with only $10 out of my pocket. My HSA account will now be enough to cover any out of pocket expenses for the remainder of the year. Now that my deductible has been met my Zytiga co-pay is a flat $60 dollars a month and Janssen still covers all but $10 dollars.

So how can they do it?
   Remember the college tuition act. The government guaranteed student loans so that anyone who wanted to pursue higher education could pay the tuition. It seemed like a great idea. In hindsight, perhaps not so much. Upon realizing the government was footing the bill, institutions for higher learning began jacking up the price of tuition. Sure, everybody can go to college if they want to but they will be saddled with student loan debt for decades to come.
    The same thing happened in the pharmaceutical industry. Everybody was required to have insurance so pharma jacked up the price of medication. They are making butt loads of money. They can afford it. I mean come on, does anybody believe that it costs $75 for one 250mg tablet. It was the same thing in the 80’s when all the auto glass companies advertised they would wave the deductible on windshield replacement. I was poor back then and carried $1000 deductible on comprehensive insurance. I had 2
Windshields replaced back then and didn’t pay a dime. That is also part of the reason insurance premiums are so high. That, and morons texting while they are driving.

    Use the system
    We have a healthcare system in place. Love it or hate it, it is what it is. The market will always dictate price. Pharma and biotech love the system. They don’t want it to change because they are making money. If patients can not afford their medication they will not have any customers and the price will drop. No more profits. Unhappy investors. You get the idea. It makes sense for them to offer co-pay assistance to patients. The down side of this however is that insurance premiums will continue to rise until there is balance within the system. One way or another we will pay. For now, take advantage of the system in place until for better or worse, something else comes along. I have shared this with some coworkers who also were elated to find copay assistance as well. Thank you for reading and always remember: 
The light the end of the tunnel is a train!