A friend writes:
“I was fortunate to meet Jeanne at ClearHealthCosts, and with her assistance I was able to get Dupixent, an injected medication needed twice a month for my niece’s eczema.
“Other medications did not treat this condition, and her doctor at Columbia Doctors Dermatology recommended this new medication.
“We learned that the cost would not be covered by her insurance company because it was not in the 2017 plan. We were told that the cost would be $34,000 annually since it was not covered.
“Jeanne gave me some suggestions on how to effectively appeal or to seek other ways of getting coverage: first to have the doctor talk to the insurance company directly, and follow any appeals procedure. She also suggested that we find out the cash price of the medication, and see if there is a generic or other equally effective drug.
“Finally, she mentioned the ‘patient assistance program’ — the drug companies have these programs where they supply medications either at no cost or reduced cost, and then use the program to build good will in the face of increasing drug prices, and also to write off the costs on their taxes.
“Eventually, with the signed forms by the dermatologist, my niece was allocated 3 refills with just the minimal co-payment of $120 per month.
“The medication was shipped from the specialty pharmacy to home.
“The drug has been a miracle to date for her and we would not have been able to get it without the advice of how to pursue the system available to Americans when denial from treatment has occurred.
“The drug company supplied the drug, not the insurer. My niece is being monitored every two weeks, and her supply is two injections a month, for four to six months.
“Your advice resolved this problem for us, which we thought was impossible. Knowledge of the health care loopholes is the savior- So very grateful.”
By way of background: Dupixent was approved by the Food and Drug Administration in May 2017. Like many other drugs, it may be denied by the insurer for reasons that are opaque to the patient. Here’s an NBC News article about it. You will note that NBC quotes the companies making the drug, Regeneron and Sanofi, as saying “there is no single price for the drug.”
“The Wholesale Acquisition Cost (WAC) of Dupixent in the United States is $37,000 annually. Actual costs to patients, payers and health systems are anticipated to be lower as WAC pricing does not reflect discounts, rebates or patient assistance programs,” the companies said.
Patient assistance programs like the one that helped my acquaintance are controversial for many reasons — in that they tend to alleviate an immediate problem for one patient, but can also result in 1) higher insurance premiums, because the insurer is often paying its portion of the price while the patient may pay little or nothing; 2) higher taxes, because the drug manufacturer often writes the cost off on its taxes; 3) no real attempt to address the skyrocketing cost of drugs; 4) skirting of insurers’ regulations on appropriate use of medications; 5) little or no examination of generic alternatives, because if the brand-name drug is free, then why bother?
Patient assistance programs go by various descriptions — manufacturer’s coupon, non-profit foundation aid to patients, short-term assistance with drug costs. We hear that they are likely to be cut back for some of these reasons. Here’s a piece about the topic; it’s a little arcane, but it does explain some of the ins and outs.
Also, we have heard recently that the drug companies are fighting back to preserve these programs. Here’s a story about that; it’s another version of how the struggle over money goes on every day in health care.
For more information about buying medications: Here’s our page on “Buying prescriptions,” with a number of resources.
Here at ClearHealthCosts, we receive several requests a week via friends or through our company contacts from people who want us to argue a bill or a denial for them, or appeal for a reversal.
We do not do individual consultations. We routinely refer people to our prescription page (see above), to our blog to search on a specific item or procedure (try MRI, appeal, birth control pills or mental health), and to our series on billing:
If you have an experience you’d like to share with us and our community, email us at email@example.com.