Paying for Prescription Drugs, Part I: Infused or Injected

Health
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By Martine Brousse

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Infused or injected treatments are common, ranging from a 32-cent B12 injection to thousands-of-dollars chemotherapy infusions. Due to medical and liability reasons, these are given in office or facility settings, and are billed to Medicare under part A (inpatient) or B (outpatient or office), and to commercial insurances under the medical benefits.

Many such treatments use brand-name drugs, often associated with prohibitive costs. These medications are not covered or payable under the pharmacy benefits of your policy.

There are options to lower your costs. Here are some tips:

1. Visit the manufacturer’s website

Almost all manufacturers offer co-pay assistance programs to self-pay patients, or those with a high share of cost. While some income requirements may be in place, they are not universal. Grants can be generous ($24,000/year for Herceptin from Genentech, for example), but will not cover off-label (that is, not FDA-approved) use. Most offices will have application forms or documentation, but may not offer it unless you ask.

Self-pay or cash patients can qualify for free drug donations, based on criteria specific to each product.

Medicare, Medicaid or Tricare patients are prohibited by law from applying directly for funds, but may qualify for indirect assistance (see below).

2. Visit public and private organizations

For every disease or condition, there is likely an organization dedicated to education and support. Cancer, for example, is addressed by various general federal agencies as well as numerous private societies.

General and focused charities may offer financial assistance and free resources. Healthwell and Copays.org offer well-known programs.

Be aware that private organizations often run out of funds early each month; applying the first week of the month is best. Grants are not retroactive, so requests should be made before a treatment starts.

3. Do it at home

Some infusion treatments, including less-complicated ones such as IV iron, IVIG, zoledronic acid for osteoporosis (Zometa, Reclast), can be administered at home by a visiting nurse. Although the first regimen will be given in the office or facility to rule out any allergic reaction, subsequent home treatments may be cheaper.

Injections such as B12, or growth factors for anemia (Procrit, Aranesp) or for neutropenia (Neupogen), for example, can safely be self-administered (some syringes come pre-filled and require no medical background to use) or via a home health agency.

In both cases, calling your insurance carrier to compare costs and verify coverage and setup is a must. As this creates more paperwork for your doctor, and extends his legal liability beyond his active control, he is likely to be more supportive if most details, such as locating an in-network home health provider, have already been worked out.

Don’t forget to take into consideration other hidden costs: time taken off work to go to the doctor’s office, parking fees, gas, risk of infection in crowded waiting rooms, or the discomfort of leaving home when not feeling well (especially after a chemo treatment, for example).

4. Use specialized mail-order pharmacies

If you are self-injecting at home without the help of a health agency, your prescriptions will be filled at your local or mail-order pharmacy. I recommend contacting TNH or US Bioservices in such cases. They may not be contracted with your insurance, but their staff is trained to locate and apply for financial assistance on behalf of patients. This service can save you money and effort.

5. Question your physician

Convenience and habit may lead to costly regimens and medications when cheaper or generic alternatives may be available. Less-expensive treatment options are often available, with the added advantage of having proven their value and effectiveness.

An active dialogue with your physician, especially when explaining your financial situation, can benefit both sides. After all, the office has an incentive to help you in order to get paid promptly and in full in return.

There may be more help out there for you than you realize. As an oncology specialist, I know for a fact that it’s true for cancer patients. Asking the office staff is the first step; doing basic Internet research is next. For those who are not computer-savvy, your local library, church or teenage neighbor may be helpful.