Yesterday I got a more comprehensive bill for Rituxan infusion treatment that makes somewhat more sense than the previous summaries and payment demands.
Yes, it is criminally expensive treatment, far more expensive than I was told it would be, more than $46,000 vs $4,600, but what's billed and what's paid are completely different things, and as far as I can tell, the $46,000+ figure billed is nonsense, a place-holder at best, a figment of imagination mostly.
The more comprehensive bill (which says "This is not a bill" just to keep me on my toes) includes all the labwork and the preliminary medications (in case I had a reaction) and the various "pushes" to get the Rituxan into me. It includes the charges for all of this and how much the "Plan" paid for various things. Interestingly, the "Plan" paid nothing for most of it, and I will have no co-pay for it either.
Well, that's a relief, right?
But all these charges add up to get to the $46,000+ figure, and it looks to be little more than bill-padding. Something that has a long and inglorious history in the practice of medicine.
Where it gets interesting is the charge for Rituxan itself.
I thought that 5mg were being administered each time I had the infusion, but according to the bill ("This is not a bill") it was actually 50mg, and each time I had the infusion, the charge for Rituxan was $21,202.
For 50mg.
Whoo.
However. The "Plan" allowed $9,492 for Rituxan and paid $8,543, leaving me with a 10% co-pay for the drug each time, or $949, which adds up to $1,898.
And literally, that is all I am being billed for. Everything else is covered by the "Plan."
Well, who knew?
Obviously those who tried to find out for me didn't and couldn't.
We'll see what the charge actually ends up being when all is said and done. While Ms. Ché and I have too much income to qualify for Medicaid, our income is low enough (so I understand, but who knows) to qualify for financial assistance from the hospital, and I've applied for that. According to what I've been told, if the application is approved, the co-pay/cost sharing will be cut in half.
We'll see.
Nevertheless, I'm stunned at the cost for 100mg of Rituxan. It's outrageous, beyond belief truthfully, yet I'm sure there are plenty of drugs on the market which I don't know about that cost quite a bit more.
We know PhARMA has zero social conscience, but still, my question is why do "Plans" pay these outrageous amounts? How much mutual back scratching is built in to this system? Who benefits? Who ultimately pays?
And what can we do about it?
Dear Che,
ReplyDelete"I thought that 5mg were being administered each time I had the infusion, but according to the bill ("This is not a bill") it was actually 50mg, and each time I had the infusion, the charge for Rituxan was $21,202."
According to wikipedia, the wholesale price for Rituxan in developing countries is $148- $496 per 100 mg. The NHS in Great Britain pays 182 pounds for 100 mg. [Teri's note: 182 UK pounds = 233 US dollars]
Looks like there is some SERIOUS price-gouging going on, even with the reduced amount "The Plan" eventually came up with for your bill. What a con!
Here are a couple of pertinent paragraphs from the wikipedia entry on Rituxan:
******************
Rituximab, sold under the brand name Rituxan among others, [...]
[...] Rituximab was approved for medical use in 1997.[3] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[4] The wholesale price in the developing world as of 2014 is US$148–496 per 100 mg.[5] In the United Kingdom this amount costs the NHS approximately £182.[6]
[...] Rituximab is currently co-marketed by Biogen Idec and Genentech in the U.S., by Hoffmann–La Roche in Canada and the European Union, Chugai Pharmaceuticals, Zenyaku Kogyo in Japan and AryoGen in Iran.[citation needed]
[...] It is on the World Health Organization's List of Essential Medicines, a list of the most important medications needed in a basic health system.[41]
In 2014 Genentech reclassified rituxan as a specialty drug, a class of drugs that are only available through specialty distributors in the US.[42] Because wholesalers discounts and rebates no longer apply, hospitals would pay more.[42]
Originally available for intravenous injection (e.g. over 2.5 hrs), in 2016 it gained EU approval in a formulation for subcutaneous injection for CLL.[43]
Patents on the drug in expired in Europe in February 2013 and in the US in September 2016.[44] By February 2017 several biosimilars had been approved in India and one biosimilar had received approval in Europe.[44] [...]
https://en.wikipedia.org/wiki/Rituximab
Wow, this could get really interesting if I follow through. I'd seen the Wikipedia article but didn't read it thoroughly, and I was not aware of the price difference elsewhere, nor the designation of Rituxan as an "essential" drug.
DeleteA couple of hundred dollars for 100mg compared to the $20,000+ that was "allowed" by my insurance, and the $17,000+ that they paid.... leaving me to pick up the balance...
Somebody is getting very rich off of this, a number of somebodies. Makes the EpiPen rip off look tame, no?
Jeebus, I despise these people.
It's truly stunning. If the patents have expired, doesn't that mean someone can start making generics? (I see they have approved generics in India and Europe, why not in the US?) Generics aside, the price the insurance company paid - or told you they paid - is unbelievably higher than the wholesale cost. Orders of magnitude higher than any market could explain.
ReplyDeleteNot sure where you go to get an explanation or have someone follow up on this sort of thing, but Jesus, it should be illegal as hell.
- T
Ah, a clue (from the original wiki article I quoted before): "In 2014 Genentech reclassified rituxan as a specialty drug, a class of drugs that are only available through specialty distributors in the US.[42] Because wholesalers discounts and rebates no longer apply, hospitals would pay more.[42]"
ReplyDeleteSo even though the patent expired, the maker can hold onto the drug, as they are the "specialty distributor".
There are several reasons a drug can be classified as a "specialty drug". I would hazard to guess, because the wholesale price is so low, that the pharma company did it in this case just because they could. Turns out a lot of drugs are now listed as "specialty drugs", and they can charge whatever they want for them.
Here's an article on specialty drugs:
https://en.wikipedia.org/wiki/Specialty_drugs_in_the_United_States
It pretty much sounds like the FDA colluding with favored pharmas, but what the hell do I know?
This is getting more and more amazing. Tomorrow I see my rheumatologist -- who ordered the Rituxan infusion when nothing else worked -- and I'll ask. I know the staff had the devil's own time trying to find out what the costs would be, and what they found out was... erroneous.
DeleteThere could be a story here. Thanks for the research. The more I look into it, the more interesting it becomes.