Enbrel Copay - HOLY COW!!

[SuzanneT]

I've gone through the approval process with Blue Cross, waited for the TB test results, and now I'm just waiting for them to send my Enbrel.

The pharmacy just called and said I've been approved for 100mg / week for initially 3 months, and that my copay would be $791.

$791!!!! Good grief, there is no way that I can do this! And I'm sure that I won't qualify for assistance as I have a good job. But I sure don't have that kind of money sitting around.

What do people DO???

[Allie]

Suzanne,

Have you double checked your company's policy yourself? My policy is capped at a certain dollar amount, so my co-pay was only $40 a month. The catch was I could only procure 1 month at a time.

Good Luck!

[NL]

With my Blue Cross insurance, once I spend $500 in one year on prescriptions the rest are at no charge. It's something to look in to. Luckily, my copay is $30 a month, one month at a time.

How much is a shot worth?

[MikeK]

:( :eek:

You might want to give Enbrel a call. A couple of years ago, they were able to help Sue (beachbound) significant lower her Enbrel related co-pays by arranging to have her prescription filled by a mail order pharmacy. Here's the links to the threads where she describes her experience:

http://www.psoriasis.org/forum/showthread.php?t=11307;

http://www.psoriasis.org/forum/showthread.php?t=11753.

I hope this helps.

Mike

[alli]

Suzanne,
That sounds to be like you have a 50 % co-pay. I'm looking at a recent scrip for my enbrel and the total cost for 4 50mg shots ( a one month supply) was $1457.49. I also have bc/bs of California and on my plan ( PPO)the most I have to pay is $100.00 per scrip. That co-pay is high compared to others.
Do you get your insurance through your workplace? Perhaps they offer different plan options at different costs. This might be another option for you.

[SuzanneT]

Yes, my insurance is thru work, and I just asked HR to pull a copy of the coverage. It states "...... self-administered injectable drugs, except insulin, 30% of the negotiated fee (subject to brand name prescription drug deductible if applicable." .........."Certain high cost drugs (injectable, infused, oral or inhaled) are obtainable only through PrecisionRx Specialty Solutions." There is a max out of pocket of $1,750 per year, but I think that only is for medical, not prescriptions. Mike, I'll give Enbrel a call, but this already is through mail order pharmacy. I think I'm out of luck!

[SuzanneT]

NL, if my math is correct........... $792 copay = 30% of $2636. At 2 shots per week, that's 8 shots per month. $2636 divided by 8 = $329 per shot.

[luvwinnie]

I am so sorry to hear this. I don't know how they expect people to afford this! I have GHI and our copays for Enbrel are the same as with any other drug.

[chaimFL]

The pharmacy just called and said I've been approved for 100mg / week for initially 3 months, and that my copay would be $791.

.........."Certain high cost drugs (injectable, infused, oral or inhaled) are obtainable only through PrecisionRx Specialty Solutions."....

Your first post mentioned "a pharmacy" and your second post mentioned the need to use PrecisionRx Specialty Solutions...is that the pharmacy you are using or did you drop the Rx off at a local pharmacy?

I know that my insurance (Humana PPO) gave me a similar co-pay if I was to use a local pharmacy, but if I used Specialty Rx (a mail order pharmacy) my co-pay dropped to $30/month.

[jessicastranz]

I would call Enbrel's Enliven Services. They are SO, SO helpful! Call 1-888-4-Enbrel. That copay is just crazy. I even think they have an option for people with insurance questions.

[tanya01]

Join the club! I just picked up my Enbrel today and my copay was $685.72!! I need to reach $2500 in prescription copays before my ins. will cover all. But for me, Enbrel is worth every penny!! Summer clothes, here I come!!

[SuzanneT]

I called Enliven. They took all my insurance info, and said that they will contact the insurance company and my dr. for me, and that they would get back to me within 24-48 hours. I also called the company who administers our insurance plans at work and she is looking into switching plans for me. It just so happens that May is open enrollment for us, and the only month out of the year that we are allowed to switch policies. I also called my dr., and left her a message regarding the copay, and they are going to look into it as well. If I can think of anything else, I will try that as well!!! It just doesn't make sense, when I read that others are paying the standard copay, and the fact that I have never paid more than a $20 copay with my insurance before. And yes, this is through the mail order pharmacy PrecisionRx Specialty Solutions. With any high cost medicines, Blue Cross (at least my HMO plan) requires that you fill the RX through PrecisionRx Specialty Solutions. Thanks to all for your help - at least I will know that I tried everything I could!!

[mamaooch]

I am a teacher and I have BCBS State Employee. I was on Embrel from January until May and the copay was $50 for a months supply. The rhemy switched me to Humira which is normally taken once every two weeks, but my Doc put me on it every week and the copay is still only $50.

I hope they get your copay down to what it needs to be. Good Luck.

Cindy

[SuzanneT]

I wonder what their criteria is for determining a "high cost drug"???? I'm currently taking Soriatane which is about $500 a month (and my copay is $20). Personally I would consider $500 high cost, but I guess they don't, as I can have that filled at a regular pharmacy!

[Stillworking]

The rheumy wanted to start me on Enbrel, but the insurnce copay was very high (500 per month) With a bit of research, I found that the insurance would cover Remicade at 100% and the Rhuemy was very happy to prescribe and administer. The sad part is that I work for the government and our insurance is supposed to be very good. Perhaps a bit of research would go a long way for you too

[tonka42100]

Part of the problem with injectables of any kind other than insulin is that many ins plans consider them therapy/medical,not just as rx's. sadly that can mean much higher copays if it is something you inject yourself rather than a treatment done in the dr's office. Almost all of the biologics are considered specialty drugs by a great number of insurance plans. Not that it will help right now,but,in another year or 2 you will see the co pays go down for these as well.
Just a note on the zyrtec co pay. Ins companies look at the drug class and what's available. Now that claritin is otc,the zyrtec and allegra co pays have gone through the roof. On the bright side. If it works for you,Allegra has a generic available now. Fexofenidine.

[SuzanneT]

Not good news............ first I found out that the $1750 max out of pocket per year only covers MEDICAL expenses - there is NO cap on prescription copays. So, $791 x 12 months = $9,492 per year. Yikes.

The Enbrel folks called me back to tell me that they had in fact verified that it would be a copyay of $791 per month. Okay, I knew this............! They transferred me to the dept that helps with underinsured or non insured. I gave them more info, and even with my job / income they thought that I might qualify for something. However she said "I don't want to get your hopes up....... we have had so many situations like this that we're running out of money. The maximum per person for psoriasis / psoriatic arthritis is $1400." Well, that would be less than two months.

Not sure what I'm going to do now. It looks like my only option would be to switch insurance plans - and the only plan that might give me coverage for Enbrel would be Kaiser. I would then have to go throught the whole procedure of switching doctors, etc. No guarantee that I would have Enbrel prescribed either. I have PPPP on my hands and feet, and right now (it's a bit ironic, but I am thrilled!) the Soriatane is working really well. Not sure if it's temporary, but it looks the best it has in years and a new doc might not see how bad it was a month ago when I could hardly walk on my darn foot. So I'm not sure WHAT to do.

[nomobties]

This will be a small comfot. Please dont forget that if you are itemizing, all medical expenses is tax deductable. This of course will not apply to everyone. Just a thought.

[RichJ]

hi stillworking and nomobties,
welcome to the p family. you have met some of the wonderful people on here and will find alot of great info. welcome and nice to meet you.

have a good day all

richard

[baka83]

SusanneT
I have a 25% copay with the original dose at 100mg a week, somewhat similar situation. My only recourse is to do only 1 50mg shot a week and pay 328.00 a month. I cannot afford the 100mg at 656.00.
Anyway the one shot a week is working and I have cleared up, I still have the discolaration where the P was but I am wearing short sleeve shirts and shorts again, I am almost human.
My insurance stinks but I am glad to have what little I have. When I was on 100mg my system was doing weird things, also got a few infections so I am satisfied with the 50MG a week.
I did get a cold a little bit ago and I did not go off the enbrel, the last time I was on it I was doing 2 25 MG aweek and got a cold and went off it and some of my P came back and stayed. No matter what, I am going to stay on it. Hope this helps a litte bit, 50MG a week is better then none and you save a little money. To bad it has to be so exspensive. They just don,t know what we endure. Peace be yours

[psudeke1]

Suzanne,

I was on an Aetna plan and was paying $136/month for Enbrel (supply of 4 SureClick pens), but my company recently switched to United Healthcare (a nationwide provider) and now I'll only pay $40/month. So there is coverage out there. Don't be discouraged.

[mikealex80]

Just a thought for you. I'm not sure what you've tried or haven't. I'm on Remicade and since it's an infusion not a prescription it doesn't go through my prescription coverage. All I have is a specialist co-pay for each infusion. It may fall under your medical cap.

[jalapeno2238]

I am the caregiver of a beautiful aunt who is depressed because of the Psoriasis she has over her arms and legs. She has medicare insurance(SSI) This is all new to me so I am doing research. I dont know if this insurance will pay meds like Xtrac, etc. She has had this for years and she said the doctor has just giving her cream...Now this is all over her both legs and both arms. would you know what I need to do to help her.

[MikeK]

I am the caregiver of a beautiful aunt who is depressed because of the Psoriasis she has over her arms and legs. She has medicare insurance(SSI) This is all new to me so I am doing research. I dont know if this insurance will pay meds like Xtrac, etc. She has had this for years and she said the doctor has just giving her cream...Now this is all over her both legs and both arms. would you know what I need to do to help her.

Hi Jalapeno2238!

Welcome to the Board. :cool: Nice to meet you. Thank you for being there for your aunt. :) I'm sorry to hear that she's going through such a rough time. :( I just posted a copy of your introduction to us in a brand new thread. (Here's a link to it: http://www.psoriasis.org/forum/showthread.php?p=307201#post307201.) I figured that you'd get a better response that way. (I'm going to be sharing some additional thoughts, that hopefully will be helpful to your aunt in the thead that I started.)

I hope this helps.

Mike

[nocure4diseased1]

Hi SuzanneT ,
I agreee my first name is Pat aka nocure4diseased1 , i know exactly what u r going through , for i myself was off of Enbrel for a while due to insurance change and the new insurance wanted me to be on Methotrexate or however you spell it , i told them no way will i add insault to injury due to the fact that Methotrexate can cause problems with your eyes and mess up your liver and mess up your stomach i have enough to deal with my Psoriasis letalone adding to it , besides i failed Methotrexate 3 times ! lol and my Doctors was fighting them tooth and nail to get me back on Enbrel because at that time i as covered from head to toe with Psoriasis , i could not move , sit or even sleep due to the seriousness of my condition my regular Dr. took before pictuers to tell them yes i need to get back on Enbrel now ! and finaly they finally allowed me to get on what they call a maintanance dose of 25 mg 2 times a week instead of the usual dose i was takeing of 50 mg 2 times a week and i can not even begin to tell u how much better i feel , i wish i can show u the before pics and me now , but the battle is not over yet i do not think the battle with my insurance will ever end :( , i have 3 more deliveries of enbrel left coming to me and after that i do not know what to do :( , there is no way i can pay $3,824.24 per month for this drug i so despertaly need called ENBREL i never again want to be the way i was 3 months ago when i was was covered head to toe with this dreadful disease , i just hate seeing my Dr. and my Nurse fighting my insurance for me they do not need that kind of hassel they have enough on their minds letalone fight with my insurance for the medication i so desperately need . let me just say if it was not for ENBREL i would not be here today !

Sincerey ,

nocure4diseased1

Camp Verde Arizona ,

nocure4diseased1@npgcable.com

[ATimMcGrawLover]

I used to take this drug and was able to get copay assistance through The Chronic Disease Magagement Group. I paid the first $50 and they covered the rest. It may be worth it for you to investigate it. You can do a google seach for Chronic Disease Management Group or go to their web site at www.diseasetrak.com

Good luck to ya.

I still have some Embrel in my fridge (4 vials, a months worth.) I wonder if I could send it to you? Or is that againt the law???? :confused:

Tina

[rosy3939]

Sue, I can sure sympathize with you and your issues with your insurance co pay. I am now after of years of having a quality health insurance policy, having to deal with similar issues. I have been on Raptiva for a little short of two years with great success. I am almost totally clear for over a year and half and don’t ever want to go back to be totally incrusted again. I had carried my Cobra benefits for the legal limit of 18 months after moving from New Jersey to Arizona. It was worth the cost to be to ensure quality coverage and protection not only in getting my Raptiva but all medical service that I required or would require in the future.

Currently I am now being covered under my wife’s plan, United Health Care. A policy that is totally useless. Although the by monthly deduction from her pay check to cover me as a dependent is $198 a pay period. Add to that a snake oil ridder which is call a Medical Saving Account and between the two created a sense of false hope and useless benifits.

My current plan has a deducible of $2,500 per calendar year which runs from Jan1, to Dec. 31st. In January it starts again. Although the co pay is higher that before at $125.00 per three month shipment vs. the $75.00 previous co pay that not the part that is troublesome, before I would be eligible I would have to anti up the $2,500 deducible now and again come Jan 1st.

I am currently on nothing right now and waiting for the rebound to start. It has been almost three week without a shot of Raptiva. Now before anyone yells that I need to get to the doctor I am on the way as soon as I finish this response. I will be looking at other possible solutions but my beloved biologics seem to be out of the question. I will be looking into Cyclosporene which although it is expensive approximately $120.00 per week depending upon the dosage is I think manageable. Also been in contact with Raptiva, SPOT (single point of contact), reps too see if there is anything they can do to assist but both Carol and I work full time and we do not quality for much help. So I will try to approach this dreaded disease from another front and hope I can keep it under control.

I will also continue to work for a cure and will dedicate all my efforts to the presidential candidate this year who will promise to work for and implement a Universal Heath Care plan so that no one should have to be denied health coverage they need.

Will update further to let every one know how this plays out.

Mitch Rosenberg

[Sharkgirl]

If enbrel WAS coated in gold, taking would be a happier affair. Unlike wut the comercial thing says, it HURTS!!! Oh well....

[danamelici]

I have recently been prescribed Enbrel for my HORRIBLE Psoriasis and was pleased with the copay and the results thus for. After the first month, I went to go refill for that month and my copay went from $40 to $2880...thats right $2880!!!!!! I called my insurance company and it turned out I have a $4000 max on scripts at pharmacies so after the first month I had already maxed out for the year. I have been devestated becuase I have been struggling for years using topicals, steroid injections, uv light treatment, laser treatment, etc and Enbrel was and is the only product that has yielded such signficiant results increasing all aspects of my wellness: physical, emotional, mental. My physicians assistant at my dermatologist office enrolled me in a copayment assistance plan and they were able to cover this months copay leaving me with only a $50 bill but that program has a cap as well. What am I going to do? If anyone can direct me to where I have to go from here I would appreciate it.

Dana Melici

[MikeK]

I have recently been prescribed Enbrel for my HORRIBLE Psoriasis and was pleased with the copay and the results thus for. After the first month, I went to go refill for that month and my copay went from $40 to $2880...thats right $2880!!!!!! I called my insurance company and it turned out I have a $4000 max on scripts at pharmacies so after the first month I had already maxed out for the year. I have been devestated becuase I have been struggling for years using topicals, steroid injections, uv light treatment, laser treatment, etc and Enbrel was and is the only product that has yielded such signficiant results increasing all aspects of my wellness: physical, emotional, mental. My physicians assistant at my dermatologist office enrolled me in a copayment assistance plan and they were able to cover this months copay leaving me with only a $50 bill but that program has a cap as well. What am I going to do? If anyone can direct me to where I have to go from here I would appreciate it.

Dana MeliciHi Dana,

Welcome to the board. :cool: Nice to meet you.

I'm at work -- which means that I'm NOT supposed to be here :rolleyes: -- so I'm going to have to keep this brief.

I'm going to give you a link to a "must read" thread that was that was started by Leslie (Momtotwogirls). She took the time to give us the links and information about some assistance programs that she came across. I added the links to some assistance programs that have either been discussed here on the board or that other people have told me about. There's even links to a couple of posts by NPF staff members that give links to the assistance programs that they know about. We don't know very much about most of these programs, but it can't hurt to check them out. I can tell you that Miranda (LadyFraser) and Jessica (stormechaser) both got assistance for Enbre thanks to a program called www.needymeds.com. (It sounds like a scam site, doesn't it?) (Jessica also got assistance for another medication call Remicade (www.remicade.com)).Miranda got assistance while her husband was transitioning from being self employed (with no benefits) to working for the government with excellent benefits. She shared her experience in this thread (circa 2003) : http://www.psoriasis.org/forum/showthread.php?t=3979. Jessica shared her experience in this thread (circa 2005): http://www.psoriasis.org/forum/showthread.php?t=13119. Links to their stories can also be found in Leslie's thread.

Here's a link to Leslie's thread:
http://www.psoriasis.org/forum/showthread.php?t=12379.

Enbrel has an assistance program called the ENcourage Foundation. The ENcourage Foundation is discussed in this thread:
http://www.psoriasis.org/forum/showthread.php?p=266709&highlight=programs#post266709. Unfortunately, their website (www.encouragefoundation.com) seems to be down at the moment. Enbrel's customer assistance hotline -- Eliven Services -- should be able to point you in the right direction. Here's a link to their website: http://www.enlivenservices.com/

Sue (beachbound) was able to significantly lower her Enbrel related co-pays when she called Eliven Services, and they made arrangements for her to recieve Enbrel through a specific mail order pharmacy. She discusses her experience in these threads:

http://www.psoriasis.org/forum/showthread.php?t=11307; and

http://www.psoriasis.org/forum/showthread.php?t=11753.


Sorry for the rushed response.

I hope this helps. Good luck! Keep us posted.

Mike

[alli]

Hey Dana,
I knew Mikek would come through with a ton of information for you. I don't know what co-pay assistance program your derm worked with, but Enbrel has a program called ExpressStart. I think it's for new patients only, so tell them you're new to enbrel and explain your insurance drug plan to them.

The number is 1-877-888-8054.

Good Luck and keep fighting to get the treatment you need!!

Alli

[Sweet1plum2000]

Enbrel is so expensive that when my mother needed it - we could not purchase it at all. Just watched it help others. She ended up going into a nursing home because the income limit is much higher for a nursing home then living on your own. She was unable to walk anymore. In Texas the income for a nursing home is anyone under 1800 single is covered in full. She went into the nursing home and Enbrel was completely covered. She started taking enbrel and felt so much better she almost jumped out of bed - but not walking for four years had it's toll. She had two new knees in surgery, then they taught her to walk again after four years. If took months and then she was a new person walking and taking Enbrel. She talked to the social worker and she was well enough to leave the nursing home and live on her on. We have a Community Based Alternative program and the state will pay for everything they did in a nursing home if you live on your own. So she got an apartment and she gets her social security check/disability and she gets all her medicine through the CBA program, home health care 40 hours a week, meals on wheels, and a home physician that comes to the home. It is cheaper for the state for her to live on her own and pay for all the meds, and helpers - then it is for her to stay in a nursing home paying the nursing home costs, and meds, and more. Mom has to pay her own rent, and pay for living expenses for phone, tv and groceries, but not for the health care and meds -

The CBA program is not part of Medicaid. So you might search the web for the CBA program and your state name to see what they might call it in your area.

[ouchyk]

This is great information to know thanks so much for sharing it!! And best wishes for continued health with your sweet mom!!

Karen

[FiFi]

I've gone through the approval process with Blue Cross, waited for the TB test results, and now I'm just waiting for them to send my Enbrel.

The pharmacy just called and said I've been approved for 100mg / week for initially 3 months, and that my copay would be $791.

$791!!!! Good grief, there is no way that I can do this! And I'm sure that I won't qualify for assistance as I have a good job. But I sure don't have that kind of money sitting around.

What do people DO???

Hi,
I know this is a very discouraging time I myself went through the same exact thing the co-payment was so much I told the doctors that there was no way I could afford to go on the Enbrel regardless even if it meant I could get clear. I have a great dermotoligist and she recommended I get a hold of Amegen and I did They gave me a web site http://www.healthwellfoundation.com I submitted a application yes alot of paper work and they got a hold of me it took about 6 months but I qualified for 100% coverage!!!! My husband is the only one working since I got sick and our income a year is around 58,000 I've been off the Enbrel for almost 9 mo. and lost my eligability so I have to re apply again when I'm done with my operation. I had to go off the Ebrel due to infections. But I have to go back on with methitrexate injections along with the Embbrel my Rhummy said. so good luck! Hope this helps!
*also here is some more web sites to check into,
www.uneedpsi.org, www.patientadvocate.org, www.copay.org

[DEBAK]

Check with you HR and insurance to see if the coverage would be better if the shot was administered as an out patient by an MD office or hospital based out patient treatment clinic..if so arrange to have the shot given to you rather thatn give it to yourself. Also discuss with your rhuematologist to try Remicade rather than Enbrel as it HAS to be given by the MD office as an IV infusion...you may have better coverage with the IV infusion. good luck

[blacklitcanopy]

my copay for enbrel sureclick 50mg 2x a week is 621$ a month... it's amazing. you have to pay a couple hundred a month to have insurance and then even with it you still can't afford to get what you need. i don't get it. health care should not be for profit. thank god for the easy step program... even though my pharmacy just tried to tell me that it didnt cover the 50mg, only the 25mg.

[mickeypearl]

i got 8 50mg Enbrel doses.... refrigerated. but i dont need them so i will get rid of them to anyone that truelly needs them for $500

[stametst]

I've gone through the approval process with Blue Cross, waited for the TB test results, and now I'm just waiting for them to send my Enbrel.

The pharmacy just called and said I've been approved for 100mg / week for initially 3 months, and that my copay would be $791.

$791!!!! Good grief, there is no way that I can do this! And I'm sure that I won't qualify for assistance as I have a good job. But I sure don't have that kind of money sitting around.

What do people DO???



Dear SuzanneT:

I know exactly what you mean!! I have to take Humira and for one month supply it is over $1,800.00 per month. If it weren't for the patient assistance program of Humira I don't know what I would do. The only way I could get on the PAP was of course, no health insurance and being unemployed. Even when I was working I was paying for family coverage for health insurance over $650.00 per month for BCBS. The copays were terrible to see the PCP was 30.00 to see a specialist was 45.00. Meds were starting copays were 35.00 on up.

Have you called Enbrel perhaps they would be able to help you. Also, check with your dermatologist and see if he /she has any suggestions. It won't hurt to ask them.

Please do us all a favor and write your congress person, National Association of Insurance Companies, Senators, TV Media, Newspapers and any one else you can think of. I hope to be at Capitol Hill Day on February of 2009. :)

[Moderator]

I still have some Embrel in my fridge (4 vials, a months worth.) I wonder if I could send it to you? Or is that againt the law???? :confused:

Tina

i got 8 50mg Enbrel doses.... refrigerated. but i dont need them so i will get rid of them to anyone that truelly needs them for $500

Dear Mickeypearl,

We fully understand the hardships caused by the high cost of Enbrel and we truly appreciate your efforts to get your unused Enbrel to people who may need it.

Unfortunately, people frown on people sharing prescription medications with other people. In fact, -- as Tina observed -- dispensing prescription medication without having the right credentials is illegal, as is attaining a prescription medication without a doctor's prescription.

Perhaps your doctor or pharmacist may be able to assist you.

Please feel free to contact the Foundation with any additional questions, comments or concerns about this issue. You may contact the Foundation at: 503.244.7404 OR 800.723.9166. Their regular business hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. Pacific Time. Their e-mail address is getinfo@psoriasis.org.

Thanks again for your generosity and understanding.

Sincerely,

[lengel55]

SuzanneT - I'm reading this in 2008 and am at your exact spot - with the exception of knowing what the cost for BCBS will be.....if you read this (or anyone else), what is your update on Enbrel? I have not seen any posts since 2007. thanks. ONe that has had GP off and on for 37 years :-)