Drug Costs/Insurance Ramifications

[tiffanyfig]

I know next to nothing about the health insurance industry, but have been wondering lately what the ramifications of all these costly drugs will be.

I'm on Enbrel, which my insurance pays for at $1,400 a month. There's been a lot of talk about doubling the dose for people for whom the standard dose doesn't work. If I go to a double dose, it will jump to $2,800 a month I'm assuming.

I guess my big fear is that insurance companies will start refusing to pay for these drugs. Is that likely? Or are there few enough of us that it doesn't make a difference (even with RA and Crohn's patients)? Can anybody explain how all this cost stuff works?

[chaimFL]

Insurance companies make money off healthy people that have very low medical expenses, which is the majority of people. If the new drug law that allows drugs to be imported from out of the US gets passed that will lower drug costs drastically. If Enbrel goes up, insurance pays more, but they will still cover it. Insurance is an odd business, but keep this in mind......I went about 2 years with out treating my p so I only went to the doctor amybe 4 times in that period of time, my wife during those 2 years had about 4 doctor visits, and my son had 6 or so.......I am paying over $800 a month for medical coverage, which is $19,200 over 2 years and I didn't use much of that and that is the norm.

[jperng]

hi Tif.. what insurance company do you have? I am getting ready to get on the Enbrel Train as well.. and am very concern about the cost.

[rosee_posey]

Hello Tiffanyfig,

Basically all insurance companies (health, auto, home, etc.) work the same - An insurance company exists to make money. It makes its profits off of the INTEREST of the INVESTMENTS that it makes with the money collected from its membership. They save a portion of the money they collect from their membership to pay off claims as they go along.

The key to the survival for an insurance company is to save as much money as they can for themselves so they can continue to invest it and make more money. It is in their best interest to keep the claims as low as possible.

With that in mind, depending on who your insurance company is, you will need to prove:
1) The standard dose of Enbrel is not effective enough for you over a reasonable course of time; AND
2) There is medical evidence to prove that a double dose may be effective in your case.

Of course, this will be done in consulation with your doc. All insurances and doc practices work differently, so you might be able to get the double dose with no trouble at all, if you are lucky.

Let us all know if you get it! I'm definitely interested!

Hope this helps,
- rose