The “Medicare Price” of Enbrel Is Not Changing for 2012
There is a very confusing story about the price of Enbrel — of Phil-Michelson-the-pro-golfer fame — running in the Boston Herald November 3rd. It’s one of those anecdotal heart-string-pulling/beat-up-insurance-company articles that journalists are so good at. But like I’ve said before, don’t believe everything you read in the newspapers. I’ve identified six or seven statements that don’t make sense in terms of
- timelines (e.g., Medicare has had standalone drug coverage for only six years so this situation could not have changed after 10 years, at least from a Medicare perspective, as implied in the article)
- insurance plans (e.g, is the Herald talking about co-pays or annual costs changing over time?)
- victim details (e.g., is/was the “Medicare victim” working or not and when?)
Whatever the answers to the above questions, Medicare stands falsely accused by the Herald of increasing its price for Enbrel because there is effectively no “Medicare price” of Enbrel. There are variously priced Medicare Part D Standalone Prescription Drug Plans that cover Enbrel. The Medicare Plan Finder says a person could buy what it thinks is the strongest dose of Enbrel for half what the Herald says its “Medicare victim” would have to pay monthly. To reach the $600 a month level mentioned in the Herald article I had to quadruple what medicare.gov says is typically the strongest dosage.
(PATIENT BEWARE: I just punched the numbers in to try to agree with the Herald story; I have no idea if quadrupling the dosage from what medicare.gov says is the maxiumum is medically possible. Everyone’s situation is different and you cannot look at your healthcare insurance needs through the prism of another person’s prescription or other healthcare needs.)
In addition these prices did not change recently as implied by the Herald. The price of the lowest cost plans as they relate to Enbrel are about the same in 2011 as medicare.gov says they will be in 2012. Perhaps this was a change that affected the victim’s 2010 plan vs. 2011 plan but if that was the case, he could have chosen a different plan for 2011.
Just to be clear, Enbrel is expensive medicine. The “good news” (if you’re a half full glass sort of guy) for the Enbrel Medicare user is that he or she quickly falls into the dreaded donut hole. But he or she also quickly comes out the other side and qualifies for the catastrophic level of Part D insurance. The strongest dosage of Enbrel on the Medicare plan finder costs $26,000 and change a year under Original Medicare (that is, without drug coverage).
Remember I do not know anything about the person mentioned in the Herald story. I am simply using the Millis zip code, the closest drug store, and the strongest dosage of Enbril on the Medicare web site. The lowest annual estimated retail drug cost according to medicare.gov would be around $3930 a year (under $330 a month) for 2012. If I quadruple the dosage to match the dollar amount claimed by the Herald, the cost of the policy, co-pays, deductibles, etc. according to medicare.gov goes up to around $7200.
Given the condition of the man as described in the rest of the Herald story I think he is just getting some bad insurance advice. But if he does need to spend $600 a month on Enbrel, that means he is getting over $100,000 in medicine for about $7200. As part of a prescription drug plan that would cover other meds as well. A plan that did not exist until six years ago. (These comparisons do not apply if he has a Medicare Part C plan but I think the effect would be proportional.)
In addition, there is no mention in the Herald of Medicare Extra Help plans and other resources available. Wendy Owens of the New England Coalition for Affordable Prescription Drugs (NECAPD), which was mentioned in the Herald story, tells me that although she is also not familiar with the Herald victim’s situation, the bigger situation is that insurance plans are treating biological-based scripts like Enbrel different than chemical-based treatments. Although the effect of these insurance company actions are mitigated by federal rules and regulations covering Medicare, they can have a devastating effect on younger people requiring these types of medicines. (Conversely, the law mentioned in the Herald story would have no legal effect on Medicare if passed by the Massachusetts legislature. That’s just another way the Herald story completely confuses me.) Wendy’s organization is one of the resources anyone concerned about this issue either directly or out of intellectual curiousity should look into.
Another possible resource is Massachusetts’ Prescription Advantage program that provides some other possible financial help depending on income and formulary. As a minimum, it allows a subscriber to change Part D plans half way through a calendar year. This would have been useful to the Herald victim if that’s what happened to him (that is, his Part D plan covered Enbrel at the beginning of 2011 but then stopped).