Maggie Heim, a 59-year-old Hermosa Beach resident who was told that the… (Jay L. Clendenin, Los Angeles…)
When Maggie Heim had a recurrence of ovarian cancer about a year after her initial treatment, her oncologist suggested that she take what he believed could be a lifesaving drug. There was just one problem: Her insurer wouldn't pay for it.
The 59-year-old Hermosa Beach resident inquired about the cost of the treatment at Cedars-Sinai Medical Center, where she received care. To her alarm, she was told that the cancer-fighting drug, Avastin, would set her back as much as $50,000 a month. But that simply wasn't an option for her.
"What do you do when there's a drug out there that could be working for you, but you can't afford it because it's $25,000 a dose and you have to take it every two weeks?" Heim said.
Specialty drugs used to treat complex or rare conditions like the one Heim has are getting pricier even as a growing number of Americans with serious illnesses, such as cancer and multiple sclerosis, are using them.
In 2010, for instance, Medicare paid $216,833 a year for each patient taking the drug Recombinant to treat hemophilia, and $26,000 a year per person for Herceptin, another cancer-fighting drug. Genentech Inc., maker of Avastin, sells the drug wholesale for up to $10,000 a month, but a spokeswoman noted that the company provides price reductions for customers who can't afford the drug.
Health insurance policies, particularly those offered at work, typically cover most routine drug costs. But with specialty drug prices continuing to escalate at exponential rates, "employers are getting more assertive in managing those costs," said Mike Thompson, a healthcare consultant with PricewaterhouseCoopers.
To curb costs, he said, employers are using economic incentives such as tiered prescription benefit plans that cost employees more money for specialty drugs, and "step therapy," in which patients are required to try less expensive medications before gaining approval for pricier options.
Whether you're on the hook for high-cost specialty drugs or even for medications that treat common ailments, such as high blood pressure or cholesterol, there are ways worth exploring to save money on prescriptions.
•Participate in a clinical trial. Heim solved her cost problem by joining a clinical research trial, a scientific study of how a new medicine or treatment works for patients. The one she found enables her to receive Avastin to treat her ovarian cancer for free.
"It's an excellent option," said Dr. Richard Sagall, president of NeedyMeds.org, a national nonprofit group that provides information on programs to help people afford their drug costs. "If people are on some drug — it doesn't have to be a really expensive one — if they can find a clinical trial for it, they should definitely consider getting into it," he said. "It's the best care you're going to get. You get everything provided free."
One list of clinical trials can be found at ClinicalTrials.gov, a clearinghouse maintained by the National Institutes of Health.
•Shop around and negotiate. A recent poll by Consumer Reports found wide variation in the price of commonly used prescription drugs. The cost for generic Plavix, for example, ranged from a low of $15 at Costco to a high of $180 at CVS pharmacies.
"People need to call around and ask and try to negotiate," said Lisa Gill, prescription drug editor with Consumer Reports.
There are often affordable alternatives. In many cases, there are cheaper generic choices or simply less expensive drug alternatives. Often, you have to ask to find out. "Appeal to your doctor to find another treatment that is covered by your insurer," Gill suggested.
•Appeal the decision of your insurer and even Medicare. Federal law now gives most consumers the right to challenge their insurance company's decision to deny medical care. Your health plan must provide guidelines about how to go about the process when it denies care.
To increase your chances of success, Gill said, "Ask your doctor to intervene on your behalf and advocate for the use of the medicine you need with the insurance company."
For help fighting an insurer's decision, Californians with HMO coverage can contact the California Department of Managed Health Care at healthhelp.ca.gov or by calling (888) 466-2219. If you have a PPO, try the Department of Insurance at (800) 927-4357.
If you get insurance at work, ask your employer for help in overturning the decision. You also have the right to appeal when Medicare denies coverage.
If you have Medicare prescription drug coverage or a Medicare health plan, also consider appealing directly to the private insurance company administering your Medicare benefits, said Elaine Wong Eakin, executive director of California Health Advocates, a nonprofit Medicare advocacy organization in Sacramento.