Tysabri cost - what it costs and what my Insurance is paying

People always talk about what the drugs cost. And I've always guessed. Last night, I asked my wife to log into our Insurance account to see what the costs were. Much to my surprise, they were as follows:

Cost billed: ~6400.
Cost paid (due to agreed upon rates with Dr's office, etc): ~2100.

It may have been a hair more... but it was a lot less than I expected.

So why can't i (if I lose my insurance) pay the 2100 out of pocket vs. the 6400? Oh wait... that's the $64,000 question!

BTW - Aetna POS insurance in this case.

What are others paying for various drugs? I know my remicade used to be over 5k per dosage. Humira I never knew b/c I was on the study.

J

My remicade gets billed at $8,000 and the insurance pays just a bit over $4000. Because it's given in the doctor's infusion center, it is treated as an office visit and I pay $35.

My Tysabri is $7481 per infusion. I have a $1500 out of pocket annually and then they pay the rest. I believe Blue Cross has determined the "acceptable" amount to be $6700.

Oh, but right now my infusions are being done at a hospital infusion lab.  I am wondering if the cost and payable amount will go down if/when I move to my doctor's office for infusions.

Doctor's can set their payments anywhere, and it's absolutely meaningless when insurance is involved.  When a doctor agrees to accept a particular insurance, they are also agreeing to accept what the insurance believes is an "acceptable" charge for services.  That may be only a couple hundred dollars for something that the doctor says they charge a thousand for.  They can't come after you for the difference, only the co-pay or your 20% or however the insurance is set up.  At least, that's the way it works in the US.  Any time you use your insurance you should receive an Explanation of Benefits (EOB) from your insurance company that explains what was charged, what was paid, what was forgiven (the difference between the actual charge and the "acceptable" amount), and what you owe, if anything.  I definitely suggest you read your EOBs.  They're eye opening, to say the least.

I'm on Humira and I was told that the starter pack would be $5000 and two pen package would cost me $1600. This was ridiculous so I got Patient Assistance from Abbott for a whole year! We estimated the yr cost for Humira would be about 20-something thousand.
If you can get assistance, I would look into it, Abbott has been fabulous.

I think that's something where they have worked out a discount with the provider...provider charges a price that is 300% profit on an item or procedure, and agrees to only charge the insurance a price that is 30% profit instead.  This is what they do with hospital stuff, so I'm pretty sure that's how it also works with doctor visits and tests and other treatments when you're not at the hospital too.

The Tysabri folks might have a list. All I know is that on both Sigma and Aetna they are taking it. And the price was exactly the same on both.

J

Just a note... Since I typed my earlier response above, I realized that the $7481 was for 2 infusions! And, insurance (BCBS) is covering after I've met deductable and out-of-pocket.