Elisabeth Rosenthal reports for The Washington Post on a patient with psoriatic arthritis who was misled about the true cost of his medications in advance of starting them. Even with more than $9,000 in copay assistance from the drug’s manufacturer, the patient ended up with bills way higher than he had been led to understand. We should hold our government responsible.
N.B. People with Medicare and Medicaid cannot use copay assistance cards for their drugs.
Health care should not be a commodity, but so long as our government treats it as such, at the very least we should know what we are paying in advance of electing it. Instead, we are forced to look at a menu in what seems like a foreign language, without any prices, and then asked to accept whatever offerings we are served.
In this case, the patient’s doctor recommended Otezla to treat skin lesions and joint pain from his arthritis; and, it helped a lot. UnitedHealth, his insurer, approved coverage. But, somehow, it had what it later said was a high “negotiated” price for that drug.
The drug’s list price is $5,253.85 for a month’s supply. The patient enrolled in a copay assistance program and received $9,450. He thought the money would offset his Otezla costs for the year.
The doctor believed that the patient would benefit from UnitedHealth’s negotiated rate for the drug, which the doctor thought would be somewhere between $1,400 and $2,200 a month. The patient would be responsible for a copay and the co-pay card would offset that cost in full. After all, even a 30 percent copay would be $660 a month if the negotiated rate was $2,200 a month.
But, after the patient took the first month’s medications, he learned that he could not benefit from a low insurer-negotiated rate. And, UnitedHealth was covering only $308.34 of the cost. So, his copay card was depleted by the second month.
UnitedHealth advised him that he would owe $4,450 for the third month. After that, he would meet his out-of-pocket limit. It also claimed that its negotiated rate was $5,253.85.
In short, the patient had no idea that UnitedHealth would not offer him a low negotiated rate for the drug but rather require him to use the copay card to cover the drug at a high price. He had no idea what his liability would be. In addition, he did not know that UnitedHealth does not factor in the value of the copay card to his deductible or out-of-pocket limit.
Of note, there is a generic alternative to Otezla, which is available in Canada. Otezla’s manufacturer, Amgen, has kept a generic alternative off the market in the US through a lawsuit. But, the generic drug costs as little as $100 a month in Canada.
What to know: Before using a copay assistance card, find out the dollar amount and the timeframe in which it can be use. Also, ask how the card coordinates with your insurance. Also, talk t o your doctor about generic alternatives or less costly brand-name drugs that might treat your condition. And, keep in mind, that some health plans charge you less for some drugs than other health plans.
Here’s more from Just Care:
- 2025: Planning for health care costs in retirement
- 2026: Medicare drug coverage and costs
- Case study: Costco saves one couple hundreds of dollars over Medicare Part D
- Poll: Costs remain a major barrier to care
- Medicare Advantage costs and prior authorization rules impede access to care
