MS Medications, Insurance Coverage and 2 Ounces of Gold

I called the health insurance company’s 800 number today to check on the status of the Provigil coverage review. The inquiry was quick and easy because I had the case number handy (remember the caregiver tip: keep good records). The coverage has been approved for another 12 month period.

I’ll write a “thank you” letter to the Coverage Review Board.

I wonder why some medications require no coverage review, while others like Provigil, Aricept and Betaseron do. Generally, it seems the more a drug costs, the more likely it is that the insurance company requires a review.

I enjoy math and have played with a few numbers lately. It’s no secret that health care is expensive, but when you look at the details, the costs can shock you. Amazing, too, is that the costs for a particular drug are apparently different depending upon who does the buying.

I’ll begin with the cost issue. Let’s start with gold and use it as the standard. According to Kitco.com’s 24-hour Spot Chart for Gold, the high price for 1 ounce of gold on the New York gold market today, Sept 7, 2007, was $700.10. That’s our gold standard, $700 per ounce. For our purposes, we’ll call anything that costs $700 per ounce expensive!

A one month supply of Provigil at 2 x 100 mg tablets per day is 6000 mg. per month. 6000 mg is a bit more than 0.19 ounces or about a fifth of an ounce. 60 tablets of Provigil costs me $429.16 out of pocket.

That means Provigil costs about $2,124.80 per ounce, making it more than 3 times as costly as solid gold at $700 per ounce.

Is that not insane? It’s a white, powdery chemical compound compressed into tablet form. It’s patented, though, and there are no generics or “therapeutic substitutes” available yet.

But that the cost varies depending upon who is buying the medication is what really strikes me as odd.

The pharmacy charges my insurance company less than they charge me for the medication if I purchase it out of pocket without insurance coverage. My personal cost (without coverage) is $429.16.

My insurance company pays only $316.88, or $112.28 less per month than I would pay if I didn’t have insurance. As an individual consumer, my out of pocket costs for the Provigil would be $1,347.36 more per year than my insurance company’s costs for the drug.

I could almost buy 2 full ounces of gold with the savings my insurance company receives from my pharmacy! I just scratch my head and wonder.

Caregiver Tip: Remember to write “Thank You” letters to the doctors and review boards.