$2,900 for One Injection

I recently got a call from my specialty pharmacy letting me know that my prescription assistance plan expired a few months ago.

What is a prescription assistance plan?

It is a free program through the manufacturer of my biologic medication, which lowers my copay to just $5 each time the medication is filled. I know it saves me a big sum of money every three months, but it didn’t fully register exactly how much it saved.

I also didn’t understand until that call how vital this program is to me, our family and so many other patients with psoriatic disease.

I’m sorry, how much did you say?

The conversation with the pharmacy went something like this:

Pharmacy: Hello, Mrs. Moy. I’m calling today to schedule your next delivery of your biologic. However, I should mention first that your prescription assistance plan expired at the end of last year.

Me: Okay. So, I just need to call to renew the plan?

Pharmacy: Well, yes, but you should know that since you’ve been on this plan for three years already, you might not be able to get the same assistance. It might not be available to you any more.

Me: Oh, well, that could be a problem. Can you please tell me how much the medication costs?

Pharmacy: $2,900.

Me: That’s the entire cost of the medication, right?

Pharmacy: No, that’s just your copay. The actual cost is more than $12,000.

Me: *Gulp*

My contributions to health insurance

I currently pay $407 per month for health insurance through my employer for just my son, age 20, and me. My husband has his own insurance through his employer. My contribution for my health insurance base plan is for both medical and prescription coverage.

For medical insurance: Our in-network deductible is $2,800 annually for the two of us, and our doctor’s office copay is $40 per visit. Diagnostic tests are 20% coinsurance after meeting the deductible.

For each prescription filled: Generic drugs are $15, preferred brand drugs are $50, non-preferred brand drugs are $65, and specialty drugs are 10% per prescription with a maximum of $155. Biologic medications are considered specialty drugs under my plan.

There are a few exceptions to these costs and percentages, but this pretty much covers the basics.

How did my copay get so high?

Here’s the catch. Very few injectable medications, and only generic dermatology medications, are covered. So, that makes it very difficult to get my biologic covered for my psoriasis.

Thankfully (also unfortunately) I also have psoriatic arthritis, so my medication that treats both is written for my PsA diagnosis. This is the same situation for my son.

This means that in order to get the medication covered, the pharmacy has to bill the biologic through my medical insurance provider, and the medication has to be given in the doctor’s office. So, first I have to meet the deductible, and then after that, I will still owe 20% coinsurance.

That’s where $2,900 comes in. And remember, that is just for me. This gets more complicated and expensive when we factor in my son.

I think it was during the pharmacy phone call that the expensive reality of healthcare in the United States hit home. My son, who works full time, does not even make enough money to cover the coinsurance, let alone pay for food, gas, or doctor office visits.

So now what?

Thankfully, the pharmacy gave me the information to get re-enrolled in the prescription assistance plan that covers my coinsurance cost. It was a simple process over the phone, and I was extremely lucky to be approved for another year, as well as my son. This time, I had tears of joy.

The assistance plan did come with an asterisk. It will only cover $10,000 each year. I get my prescription filled four times each year, meaning my coinsurance each year is $11,600, meaning I will still owe $1,600 for my final injection in December.

I’ll work ahead to find other options to help with this final payment, but for now, I’m super excited to only pay $5 per injection for a medication that has been a godsend to managing my diseases.

What you can do

If you find that your copay or coinsurance is too high to get your medication, ask your doctor or pharmacy for the manufacturer’s discount or assistance program. Sure, you’ll likely have to answer a bunch of questions, and most likely there will be a pitfall or two, but you might qualify, and even qualify for a few years.

You can also reach out to the National Psoriasis Foundation’s Patient Navigation Center. It is a free, personalized service for patients and caregivers. Staff can help you find access to care and treatment when you can’t afford your medications.