Drug Costs

 I got this random email the other day from my pharmacy.  I use a mail pharmacy so that I don't actually have to go and get my drugs from a physical location each month.  It helps that they deliver meds in 3 month supplies.  Anyway, I got an email from them that directed me to look at my claim details.  I've always been a little curious as to what things 'cost' medically.  OH MY FUCKING GOD!!!!

I'm going to list my meds, list MY monthly cost of said meds (or deductible), and what my insurance pays.  I feel a little strange putting out ALL of my meds in one place in one post, so I'll obscure some of them (I decided to leave them all in.  It still feels strange.).  I'm going to leave some of the big brand names though as they're obviously going to be the most expensive.  

Basically, my meds come in a few forms.  There's one that I buy myself as it's not technically prescribed, just recommended.  That's my fish oil.  I still find it odd that my doc's orders are to just take some.  Not 1000mg once a day or 500mb twice a day... just take some.  So I buy it from Amazon and get a 'nice' one that tastes kind of like mint going down and vaguely tastes like lemon when you eventually burp some up.  Next are old generic cheap meds.  This has nothing to do with effectiveness, it's just that they've been around so long that they cost almost nothing to make.  The price doesn't even come up to my deductible so there's no insurance portion.  Then there are generic meds that are still kind of expensive.  This could be because of the med itself or the larger dose I take.  Regardless of the reason, I pay my deductible and the insurance pays a bit more on top of it.  And finally there are meds that are not generic.  My copay triples and the insurance pays a LOT more.  

And before I get to the meds, I just want it out there (mainly for the discussion later) that I have good insurance.  My drug costs start the year at a price and stay there.  I've seen drug coverage that says you have to pay 100% of the cost until you reach a minimum and that would be horrible.  Plus, my drugs go into my full health coverage which maxes to an annual out of pocket cost of $2000.  Once I hit that amount paid, insurance covers 100% of the costs with no co-pays or deductibles.  Again... good insurance.  Specifically my drug cost is set up for 3 month supplies (savings in bulk I guess).  $20 for generic, $60 for non-generic.  That goes for meds that aren't available in generic form or if my doc orders a specific formulation of the med.   

And then, as I found out with Nurtec, there are meds that cost more.  My first 1 month supply of Nurtec cost me $60.  That would be tripling my deductible again.  As I'm breaking this down to one month supplies, you'll see $6.67 for generic and $20 for non-generic.  My cost will be first followed by the insurance's portion in parentheses.  On to the meds in order of cost:

• Fish Oil $19.82
• For cholesterol
• Technically not the least expensive, but my insurance isn't part of this as it's just an over the counter medication.  Still worth putting here as my doctor has ordered it.  
• Lipitor (atorvastatin) $1.98 ($0.00)
• For cholesterol
• Cozar (losartan) $4.43 ($0.00)
• For blood pressure
• Metformin $6.67 ($0.53)
• For diabetes
• This is the first med that I take that the insurance chips in for
• Protonix (pantoprazole) $6.67 ($1.60)
• For GERD
• Singulair (montelukast) $6.67 ($2.80)
• For seasonal allergies
• This one is strange as I used to get head colds every spring and autumn.  For the longest time they'd last a couple days, then a few days, then a week, then a couple weeks.  The doc put me on this and voila, it stopped.  I honestly haven't had a head cold or upper respiratory 'cold' since.  
• Wellbutrin (bupropion) $6.67 ($15.95)
• For anxiety
• That's what Wellbutrin is technically for, although it has a lot of uses.  This is the one that I went on to help quit smoking.  It didn't to bumpkiss for that, but I noticed I didn't have a 'depressive' episode while I was on it.  When I went off, I had another bout of depression, so I went back on it.  Been on it since without any side effects or depression.  Doc says that's just fine.  
• Relpax (eletriptan) 40 MG po prn migraine $6.67 ($32.16)
• For migraines
• This is one that the price certainly comes from it's limited use.  It's only used during an actual migraine and not taken regularly.  It's old and generic (I had to look up the brand name as I've always heard it referred to as eletriptan) and has no business being this expensive.  BUT, a drug company has to drug company, amiright?
• Depakote (divalproex) $6.67 ($54.37)
• For migraines
• This is an old school anti-seizure medication but it has a lot of uses.  I think the cost is so high because I'm on a HUGE dose.  I give these out at work in doses as low as 125mg daily.  I'm on 1500mg daily.  And yes, it goes higher as my doc suggested taking it up to 2000mg.  
• propranolol $6.67 ($57.84)
• For migraines and blood pressure
• Propranolol might be the oldest medication I'm currently taking.  It was one of the first beta blockers for blood pressure and frankly, it sucks at lowering blood pressure.  It was surpassed for that use decades ago.  But for migraines, it's a common preventative medication.  Yeah, I'm on a higher dose, but it still feels expensive.   
• Lantus (insulin glargine) $20 ($105.89)
• For diabetes
• Now we're talking expensive, considering it's use.  I'm not insulin dependent, but I do require it to stay healthy, but there are those with type 1 diabetes that are DEPENDENT on insulin.  They die if they don't take it.   You've probably heard on the news that the CEO of this company raise the price by 500 percent... well, here's the price I and my insurance company pay for it.  
• Farxiga (dapagliflozin) $20 $453.16
• For diabetes
• And here we get to the ridiculously expensive.  But then again, this is still a 'new' drug.  This still gets advertised on television.  My doc wasn't comfortable prescribing it but had heard of it.  He sent me to a specialist to manage my diabetes, in part because he would better know how to manage these newer medications.  \
• By the way, this and the next med are how I got my diabetes undercontrol earlier this year.  This time last year my blood sugars were out of control and my doc had me on an ever increasing dose of insulin that didn't seem to help.  Farxiga and Ozempic stopped it and have managed it well ever since. 
• Ozempic (semaglutide) $20 ($484.15)
• For diabetes
• This is the weekly injection.  It recently got approved at a double dose, so just last weekend I got a new prescription for that.  This is the older 0.5mg dose.  I'm not sure if the cost will go up when I start injecting twice as much. 
• Nurtec $60.00 ($732.54)
• And here's the one that got me thinking about all of this.  The rest of the meds here I pay for a three month supply $60 for 'the new stuff', $20 for most stuff, or less if it's really cheap.  This one costs me $60 for a single month supply.  That's 8 doses.  IF it works well, my neurologist can prescribe it as a preventative, which means I'll take it every other day.  That would DOUBLE the monthly cost.  

So, I've never put these numbers together, but lets look at what I pay per month and what my insurance pays per month.  I'm not going to include the eletriptan as I'm not supposed to take that with Nurtec, but I AM going to include Nurtec.  I'm sure my insurance would love for me to NOT take all 8 doses every month and have this last longer but a migraine is going to migraine, amiright?

My monthly drug payment is $192.92. 

My insurance's drug payment is $1940.99

That's $2133.91 a month in drugs.  That's more than half of my take home pay. 

What would I do if I didn't have insurance?  Or what would I do if I had insurance with a maximum payout as many of them do?  I have a friend, a NURSE friend whose insurance will pay a max of $8000 a year for drugs.  Look at that max and look at what my insurance is spending.  I'd be on the hook for over $15,000 a year.  For drugs.  

Insurance wise, the numbers still don't make sense.  I pay $58.78 a pay period while my employer kicks in $235.11.  But hold on... that's a pay period, not a month.  And since pay periods go every two weeks and not a month, I need to go out to a year and then divide by 12.  So I pay $1528.28 a year and the state pays $6,112.86.  That's $7641.14 paid per year for my health insurance, which is $636.76 a month.  That covers not just the drugs, but all my doctor's visits, my labs, any and all tests and procedures.  

$636.76 a month paid for insurance with them paying $1940.99 a month for drugs. Now, I know insurance is a system built in actuary tables and not a tit for tat basis.  Yes, that's them losing at least $1300 a month on my drugs alone every month, but what is it for my co-workers?  Off the top of my head I know I have nine that take little to no drugs.  We'd collectively be paying about $6000 for say roughly $2500 in drugs.  So, the insurance company would still gain.  

And I still have trouble believing they pay that much.  I'm not quite sure how to look all this up, but there are obviously various entities involved here. 

• Me
• I pay the $60 a pay period for insurance
• I pay the $200 a month in drug co-payments/deductibles
• The State (Employer)
• They pay the $230 a pay period for insurance
• The Insurance
• They pay for medical services
• They also deal with providers for discounts (more on that below)
• The Doctors
• They charge me for the visits
• They prescribe the medications and order tests and procedures
• They bill the Insurance
• The Pharmacy
• They charge me for the drugs
• They bill the Insurance for the drugs

Now the whole discussion here comes from my pharmacy's email telling me I can look at the individual claims.  But I know when I get breakdowns of what I had to pay for stuff like labwork, it often looks like this.  

The Price.  

The Discount The Insurance Company Demands.  

The Price The Insurance Company Will Pay.  

Any remainder is mine.  

So for example a recent visit for my stress test costs $895.  My insurance company has a 'discount' of $643.60 leaving $251.40.  The plan paid $106.43 leaving $144.97.  That was then broken up into a $133.14 deductible and $11.83 coinsurance, both of which I had to pay.  On the one hand that's great, I only had to pay $144.97 for my stress test (it ended up being more as I also had to pay similar amounts for it to be read.  Twice.) but what if I didn't have insurance?  Would I get billed for $895?  

And that makes me think, are the drugs going through a similar process?  Are they applying a big discount, paying a little, then leaving me with the coinsurance?  I see a claim from the pharmacy for $60, but it doesn't say what the amount charged was, the amount approved, the discount, or anything.  Just that I paid $60.  And I believe that was for the Nurtec.  

So why is this so complicated?  A doctor wants to get paid.  A specialist wants to get paid.  A pharmacy wants to get paid.  A drug company wants to get paid.  Nurses want to get paid.  Respiratory therapists and x-ray techs and RCAs and... healthcare workers... want to get paid.  And the one that doesn't belong; Insurance companies want to get paid.  

I'm a nurse.  I get why healthcare is so damned expensive.  Yes, it costs a lot of money for procedures because we use specialized equipment and it has to be sterile.  Sterile equipment expires, even if its perfectly sealed and just a cotton topped applicator (a q-tip if you will).  If it's not used before the expiration date it is trash afterwards because it's no longer sterile.  Nurses and Doctors and Surgeons and other licensed medical professionals are legally liable for their work so perfection isn't a goal it's a job requirement.  Their education requirements, licensure, license maintenance, and legal liabilities means they deserve their high pay.  

But why is there someone in between me, the patient, and my healthcare workers.  Yeah, I'm spinning off onto a universal healthcare argument when I started this out as a drug cost rant.  But they're linked.  You see, I highly doubt my insurance company is paying $450 a month for my Farxiga.  I have no doubt that it's far more expensive than my $1.98 per month lipitor, but insurance companies make deals with drug companies just like they make deals with healthcare provider networks.  The drug manufacturer agrees to the price or 'discount' or the insurance company won't approve it.  

It doesn't even have to be denying approval, they can just add extra steps.  To get approved for Nurtec, my neurologist had to show that I was on at least two preventative medications and that I'd tried (and failed) at using two prn medications.  I've tried Imitrex and was using eletriptan without success.  I'd wager that if Biohaven Pharmaceutical agreed to a steep discount that my insurance company wouldn't have made my neurologist (and me) jump through so many hoops.  

Now... what if we didn't do this for different insurance plans?.  What if we didn't do this for different insurance companies?  What if we ALL did this together?  Sure, we'd have to pay more in taxes.  But if I paid an extra $1,500 a year in taxes and my employer paid an extra $12,000 a year and we could drop health insurance... well damn, we wouldn't pay anything more than we are now!  

I don't know.  Something has to change.  The differences between the 'haves' and the 'have-nots' is getting too wide.  In this instance, I'm a 'have' and I still think it's unfair.  Who the hell could afford these prices for doctor's visits, lab tests, diagnostics, and treatments (drugs) if they don't have insurance?  

And in case you're wondering why I'm putting the politics label on this... I hate to say it but this IS political.  There is a whole political party that doesn't even want cheaper insurance, let alone health coverage for everybody.  They don't see the advantages of group buying, group negotiating, equality in care, or the societal benefits of everybody among us being healthier and likely living longer happier lives.  They think that something might be taken away from them, that there will be a government official will be between them and their healthcare, and that their prices might go up.  

You know what?  At the top of the insurance chain, something might be taken away.  I might have to pay more.  I might lose my $2000 a year cap before my insurance pays everything.  And there will be a government department/official between me and my healthcare, but that would be an official tasked with helping the citizenry of the country verses our current system where there is an insurance official between me and my healthcare who has a profit motive dictating his decisions.  And prices may well go up, but only at the very top where the 'Cadillac' plans cover everything, and in those instances that is almost always people that can afford more vs people that can't afford anything and would suddenly get equivalent health care coverage.  And yes, I'm putting ME in that category.  My prices would go up, I could afford it, and it would help get health care coverage to so many people.