I worked on contract for a few months at Prime Therapeutics. They bragged that their markup was half that of the pharmaceutical companies -- the pharmaceutical companies marked up 600%, and Prime Therapeutics was ONLY 300%!
I remember thinking, "Your mothers must be very proud."
Kyla, when the justification for a markup is that somebody else's markup is bigger, there is no service behind it, just a number they believed nobody would see.
And that is the real difference between the two. A manufacturer's list price is at least public enough to fight about in the open. The spread inside a PBM claim sits behind contract definitions the plan sponsor never sees, so most employers cannot tell you their own number. I review contracts everyday, and the reporting rights that would expose it are missing from nearly every first draft that crosses our desk.
Thank you for saying this out loud. It usually takes someone who watched it from the inside to make it undeniable.
I have a question about medicine that docs use during in office treatment. For example, my husband’s doc claims he is being charged $5000 for “PAVBLU Biosimilar (Prefilled syringe), 1mg”. My husband has traditional Medicare, which paid $1287.95 of the “Medicare Adjustment”, which is $3,357.21. This leaves us with roughly a $300 bill every month which we cannot afford. The doc is not interested in helping make this more affordable and basically told me my husband will go blind without the treatment. So…we are faced with blindness because we cannot afford the treatment that will stop it. Blindness or bankruptcy…aside from talking to my state and federal representatives, what can be done? It is a form of torture to watch my husband go blind knowing there is a treatment out there for rich people that we can’t have.
Jodi, I am so sorry. No one should be weighing eyesight against bankruptcy. A few concrete doors worth trying:
1. Pavblu is made by Amgen, and Amgen runs a charitable program (the Amgen Safety Net Foundation) that provides the drug at no cost to Medicare patients who meet income limits. The doctor's office applies with you. Ask the billing staff, not the doctor.
2. Independent charities help cover Part B coinsurance for retinal disease when their funds are open: PAN Foundation, Good Days, and HealthWell Foundation. Funds open and close through the year, so check all three and join waitlists.
3. If your household income is limited, a Medicare Savings Program through your state (ask about Qualified Medicare Beneficiary [QMB]) can eliminate that coinsurance entirely. Your local State Health Insurance Assistance Program (SHIP) office helps with this for free.
What you are seeing is the in-office version of the same problem I wrote about: the price attached to the drug has very little to do with the drug. Hopefully these provide options for you and your family.
We the people see how center for Medicare & Medicaid Innovations (CMMI) is standing up for corporation’s greed in this current Republican administration.
This is off topic, if you delay signing up for Part D plan until you need medication, YOU WILL PAY A PENALTY FOR AS LONG AS YOU HAVE DRUG COVERAGE.
Our private for- profit healthcare has diverted $79 trillion from the working class to wealthy one percent over the last 50 years.
I worked on contract for a few months at Prime Therapeutics. They bragged that their markup was half that of the pharmaceutical companies -- the pharmaceutical companies marked up 600%, and Prime Therapeutics was ONLY 300%!
I remember thinking, "Your mothers must be very proud."
Kyla, when the justification for a markup is that somebody else's markup is bigger, there is no service behind it, just a number they believed nobody would see.
And that is the real difference between the two. A manufacturer's list price is at least public enough to fight about in the open. The spread inside a PBM claim sits behind contract definitions the plan sponsor never sees, so most employers cannot tell you their own number. I review contracts everyday, and the reporting rights that would expose it are missing from nearly every first draft that crosses our desk.
Thank you for saying this out loud. It usually takes someone who watched it from the inside to make it undeniable.
I have a question about medicine that docs use during in office treatment. For example, my husband’s doc claims he is being charged $5000 for “PAVBLU Biosimilar (Prefilled syringe), 1mg”. My husband has traditional Medicare, which paid $1287.95 of the “Medicare Adjustment”, which is $3,357.21. This leaves us with roughly a $300 bill every month which we cannot afford. The doc is not interested in helping make this more affordable and basically told me my husband will go blind without the treatment. So…we are faced with blindness because we cannot afford the treatment that will stop it. Blindness or bankruptcy…aside from talking to my state and federal representatives, what can be done? It is a form of torture to watch my husband go blind knowing there is a treatment out there for rich people that we can’t have.
Jodi, I am so sorry. No one should be weighing eyesight against bankruptcy. A few concrete doors worth trying:
1. Pavblu is made by Amgen, and Amgen runs a charitable program (the Amgen Safety Net Foundation) that provides the drug at no cost to Medicare patients who meet income limits. The doctor's office applies with you. Ask the billing staff, not the doctor.
2. Independent charities help cover Part B coinsurance for retinal disease when their funds are open: PAN Foundation, Good Days, and HealthWell Foundation. Funds open and close through the year, so check all three and join waitlists.
3. If your household income is limited, a Medicare Savings Program through your state (ask about Qualified Medicare Beneficiary [QMB]) can eliminate that coinsurance entirely. Your local State Health Insurance Assistance Program (SHIP) office helps with this for free.
What you are seeing is the in-office version of the same problem I wrote about: the price attached to the drug has very little to do with the drug. Hopefully these provide options for you and your family.
Thank you! The options you provide are real and helpful in providing next steps.
What good is a “breakthrough medication” if it is inaccessible?
I have stories going back 15 years about PBMs. They're all horrid and need to be gone.
We the people see how center for Medicare & Medicaid Innovations (CMMI) is standing up for corporation’s greed in this current Republican administration.
This is off topic, if you delay signing up for Part D plan until you need medication, YOU WILL PAY A PENALTY FOR AS LONG AS YOU HAVE DRUG COVERAGE.
Our private for- profit healthcare has diverted $79 trillion from the working class to wealthy one percent over the last 50 years.
Medicare for ALL is free of ALL profit.