Wednesday, August 21, 2013

Crohn's Chronicles :: Humira Cost Provision REVISION

So I needed to update this post. Today I am struggling because the FANTASTIC news I thought I had received was well-intentioned, but sadly misinformed.


Right before we wrapped up my 6-month check-up, I decided to ask my doctor what my options were for paying for my medication. With the cost of Humira going up, I knew I needed to have a game plan for how I was going to tackle a lifetime of inevitable increases. You may or may not know, but there simply are no generic brands available for Humira {or Cimzia, it's competitor on the market}. Because they are considered "biologics" they fall under different laws/regulations than other medications. Unless these laws are changed, there may never be generic versions. So those who require these types of medications may always face the rising cost of "designer drugs."

My doctor asked if I had insurance: yes, and it pays 70% of the cost {so thankful}. He asked if I was enrolled in the Humira Protection Plan: yes, but I was told the benefits ran out a few months ago, so while they will cover a little less than 70% of that remaining amount {very thankful, for sure}, I am still left with a fairly high out-of-pocket expense every month {we're talking hundreds. per month.} And that doesn't account for the cost of check ups, blood work, vaccinations, etc. He referred me to his nurse, because he thought it sounded really high but wasn't sure.

Long story short...when I told her what I was paying, she told me I should only be paying $5.00 per month. 5 dollars. 1 Mr. Lincoln. When I asked her about the benefit running out, she said that I just sign up for a new card.  Unfortunately there are always restrictions. It sounded too good to be true, and it was. Unfortunately, our out-of-pocket after what insurance pays exceeds a $500 maximum that the Humira Protection Plan will apply each month. So I am still responsible for the balance, which is way higher {remember. hundreds. per month} than a $5 co-pay. And you cannot just sign up for a new card. You get one card only.

We have readjusted our budget, making major cutbacks to accommodate the crazy expense, and we were paying too much the entire time? I wanted to hug her right there in the exam room. Inside I was holding back the tears, screaming "do you have any idea what this means???" I believe so much in how much Humira has helped me that I would gladly pay more than $5 for the medication {we were doing what we needed to make it work}. But there is simply no reason to pay more than you should if there is assistance available. And it's comforting to know that I have access to affordable treatment for Crohn's. That may not always be the case, but for someone who is looking at a lifetime commitment of managing the disease, every little bit {for however long} helps. We will still need to continue our cutbacks to accommodate this crazy expense because I still believe in how much Humira has helped me. And unfortunately, my health is dependent on it. Because of my particular situation with my insurance company, they mandate which pharmacy at which I fill my prescription. So I am stuck {for now} with the price the pharmacy has contracted with Humira. Not all insurance companies mandate a particular pharmacy, but rather allow you shop around. If this is the case for you, SHOP around. The lower the total cost of the drug, the lower your out-of-pocket could be.

I still LOVE my doctor and am still thankful for his willingness to talk through all of my crazy questions/thoughts/ concerns/fears. And I am still so thankful for his nurse, who has done a lot of leg work on my behalf to make sure I have access to affordable care. She may not have had all of the information, but she was willing to go to bat for me, for which I am grateful. At least I may be able to help a patient in the future have better information. I am also thankful for a job whose leadership works hard to keep our premiums low and our benefits helpful. We recently switched insurance providers at work, which always instills a little fear of whether or not my doctors and medication will be covered. But the Lord has even taken care of that for us, even placing my medication on a better coverage tier, which will help with increases in the future. They told me that all injectables are rejected under our new plan, but that if I have a prior letter of authorization from my doctor, they will cover it. They also said that I can choose my pharmacy, which means I can find one with a better pricing contract with Humira {i.e. lower cost}. My plea for prayer is that this is really the case, and I'm not just getting the run around again. They could only provide me information under a dummy account, but we won't know for sure until I am an official member under the plan. {Kind of makes it hard to shop around for an insurance plan that makes sense for you, doesn't it? Sigh.}

I just see this as God's incredible provision. He knew I would be diagnosed with Crohn's, and when we thought we had to pay the higher prices, He provided. When we were stretched thin in our budget and didn't see how we could make it work, He provided. When we were not sure how things would be covered, He provided. Again, I realize things could change in a moment, but I know that somehow, some way, He will always provide. In the midst of the frustration and disappointment of the changed news, I am repeating these words to myself today. It's just as true now as when I thought this had been resolved and the news was better. My raise took affect this month, which was one of our Ebenezer Stones for how He provided when the total cost of Humira {and thus our out-of-pocket expense} went up last month. God is still good and still worthy of praise. And I know He will provide. Even if the provision looks different than what I wanted.


1 comment:

  1. Praising God for His provision and care for you!!

    ReplyDelete