Today I had the dubious pleasure of holding in my hand a bottle of medication that cost more than my car.
I was floating today in a store near my house that I work at very infrequently, when the regular pharmacist needs a day off. They don't do that much volume, but some of the meds they do dispense are crazy expensive.
Case in point. This one patient with hepatitis C. The doctor prescribed Viekira and ribavirin. Prior authorization's been taken care of, so I bill the insurance. It goes through for a wonder, I check that we've been paid more than it cost us (sometimes we aren't; we always have to check) and we did in fact turn a nice profit for a change.
Then I see the label, and discover that this poor guy has a copay of $1692.25.
So we make some phone calls. Seems that his plan has a 5% coinsurance for prescriptions. So when you have a drug that retails for $33,845 for a 28 day supply, then yeah, he's going to be out of pocket for five percent of that.
(Not that they actually paid us the full retail less the copay; we got maybe 28 grand, including the copay, with the rest presumably going into the pockets of the PBM. Did I ever mention that I hate PBMs? Our profit is in any case less than the copay, so it's not like we can waive it even if we were allowed to, which we ain't.)
No way he can afford that, so I start looking for discounts. Turns out there's a manufacturer's coupon you can download that knocks the copay down to $5.00. Sounds great; I do so, but it says it needs to be activated by the patient. He's not here, but we are, so we call them. The agent says that even though it says it needs to be activated, it doesn't really, so we should just go ahead and process it. Claim rejects: patient is on Medicare part D, which we hadn't known, and there's a law barring patients on any government insurance (Medicare, Medicaid, Tricare, etc.) from using these coupons.
So the boss asks them if there's anything else he can do to help this patient out. Agent directs him to a charity (Hep C Foundation or something like) which pre-approves him for a grant of $15,000 a year to help with the copays on this and the ribavirin, which is another $110/month, but it's predicated on his having low income, so we need to find out how much this guy makes in a year.
So we then call the patient, for the first time in this chain of events. He's understandably shocked by the copay, and wants to know why it's so much?
Boss tells him it's the drug manufacturer who sets the prices, not us. Then he comes out with a statement that I never would have thought of in a million years, but makes perfect sense in retrospect:
"This medication cures Hepatitis C. You take it for three months, and you're done. It's not something you take forever. This means that sooner or later, once everyone with Hep C is done taking it, the market for this drug is gonna die, and they won't be able to sell it anymore, so they're trying to take as much profit as they can now."
I also thought that even if it does cost a hundred grand for a course of therapy, it's still cheaper than a liver transplant.
(The one I was holding in my hand was a different, and even more expensive, Hep C drug for a different patient. That one's called Harvoni, and my wholesale cost for 28 tablets is $30,240.00, or nearly eleven hundred bucks a tablet. I wonder how that compares to the price of gold, or cocaine.)
I was floating today in a store near my house that I work at very infrequently, when the regular pharmacist needs a day off. They don't do that much volume, but some of the meds they do dispense are crazy expensive.
Case in point. This one patient with hepatitis C. The doctor prescribed Viekira and ribavirin. Prior authorization's been taken care of, so I bill the insurance. It goes through for a wonder, I check that we've been paid more than it cost us (sometimes we aren't; we always have to check) and we did in fact turn a nice profit for a change.
Then I see the label, and discover that this poor guy has a copay of $1692.25.
So we make some phone calls. Seems that his plan has a 5% coinsurance for prescriptions. So when you have a drug that retails for $33,845 for a 28 day supply, then yeah, he's going to be out of pocket for five percent of that.
(Not that they actually paid us the full retail less the copay; we got maybe 28 grand, including the copay, with the rest presumably going into the pockets of the PBM. Did I ever mention that I hate PBMs? Our profit is in any case less than the copay, so it's not like we can waive it even if we were allowed to, which we ain't.)
No way he can afford that, so I start looking for discounts. Turns out there's a manufacturer's coupon you can download that knocks the copay down to $5.00. Sounds great; I do so, but it says it needs to be activated by the patient. He's not here, but we are, so we call them. The agent says that even though it says it needs to be activated, it doesn't really, so we should just go ahead and process it. Claim rejects: patient is on Medicare part D, which we hadn't known, and there's a law barring patients on any government insurance (Medicare, Medicaid, Tricare, etc.) from using these coupons.
So the boss asks them if there's anything else he can do to help this patient out. Agent directs him to a charity (Hep C Foundation or something like) which pre-approves him for a grant of $15,000 a year to help with the copays on this and the ribavirin, which is another $110/month, but it's predicated on his having low income, so we need to find out how much this guy makes in a year.
So we then call the patient, for the first time in this chain of events. He's understandably shocked by the copay, and wants to know why it's so much?
Boss tells him it's the drug manufacturer who sets the prices, not us. Then he comes out with a statement that I never would have thought of in a million years, but makes perfect sense in retrospect:
"This medication cures Hepatitis C. You take it for three months, and you're done. It's not something you take forever. This means that sooner or later, once everyone with Hep C is done taking it, the market for this drug is gonna die, and they won't be able to sell it anymore, so they're trying to take as much profit as they can now."
I also thought that even if it does cost a hundred grand for a course of therapy, it's still cheaper than a liver transplant.
(The one I was holding in my hand was a different, and even more expensive, Hep C drug for a different patient. That one's called Harvoni, and my wholesale cost for 28 tablets is $30,240.00, or nearly eleven hundred bucks a tablet. I wonder how that compares to the price of gold, or cocaine.)
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