How expensive is UC treatment in the US?

To be blunt, the cost is INSANE. However, once you get a prescription from an American doctor, you can just order your meds from a Canadian pharmacy for a reasonable cost. 30 suppositories should cost you about $65. Not sure about the Salofalk granules. Salofalk tablets are somewhat expensive in Canada, about $125 for 150 500mg tabs. Keep in mind that different mesalamine oral formulations can be totally different in terms of effect, so you would have to figure out what is the closest available equivalent that works for you.

One of the biggest headaches with health insurance policies is determining which medication is your most affordable. Here's a basic survival guide to help you through it.

1.) Ask which UC medications are on the insurance's formulary (preferred) list and which are on their non-formulary (not preferred) list. For the lowest out-of-pocket cost, choose from the formulary list.

2.) Generics are the most cost effective. Brandnames are more expensive.

3.) Use the health insurance's price estimator tool (online insurance website, or call insurance, or ask a pharmacy) to learn what your copay will be. You will need to know which medications are applicable. The most common meds used are the anti-inflammatory, mesalamine-based medications that should be available in their price estimator:

• Apriso is brandnamed, comes in 375mg pills, a typical dose is 1,500 mgs or 4 pills daily. A copay assistance card is available from the manufacturer www.aprisorx.com/apriso/savings-card.
  
• Balsalazide Disodium is generic of Colazal, comes in 750mg pills, a typical dose is 6,750mgs or 9 pills daily.
  
• Colazal is brandnamed, comes in 750mg pills, a typical dose is 6,750mgs or 9 pills daily.
  
• Delzicol is brandnamed, comes in 400mg pills, a typical dose is 4,800 mgs or 12 pills daily. A copay assistance card is available from the manufacturer www.delzicol.com/resources/savings-card/
  
• Lialda/Mezavant is brandnamed, comes in 1,200mg pills, a typical dose is 4,800 mgs or 4 pills daily. A copay assistance card is NO LONGER available from the manufacturer, discontinued on 11/1/2017 and will not be renewed into the next year.
  
• Mesalamine DR is generic, comes in 800mg pills (generic Asacol HD) and 1200mg pills (generic Lialda), a typical dose is 4,800mgs. That's 8 of the 800mg pills or 4 of the 1,200mg pills daly.
  
• Pentasa is brandnamed, comes in 500mg pills, a typical dose is 4,000 mgs or 8 pills daily. A copay assistance card is available from the manufacturer /www.shire.com/patients/patient-services/shire-cares.
  
• Sulfasalazine is a generic,comes in 500mg pills, a typical dose is 4,000mgs or 8 pills daily.
  

4.) Once you've found a cost effective medication, call your gasteroenteroligist for a new prescription.

5.) Mail order prescriptions may have lower copays when you get a 90 day supply, instead of a 30 day supply. Check with your health insurance and ask about mail order options.

If you do decide to take this decision of moving to the US and you end up getting craptastic insurance, then do remember of goodrx.com I have insurance which is good for some, bad for some, definitely bad for the meds. So I do not use my insurance. I use GoodRx.

Without insurance, my Delzicol is about $700/month (there is no generic here because the pharmaceutical company who makes it is evil and decided when the patent ran out several years ago to create a "new" pill that is exactly the same pill only they placed the pill inside a capsule). With insurance, I think I pay $120 for a 3 month's supply. My mesalamine enemas are much cheaper since they are generic.

adamas said...
So, if I go to the family doctor first thing as I become a US resident, wouldn't he be allowed to prescribe mesalamine tablets and enemas (if I show a letter form my current doctor)? Do I need to have an appointment with the specialist first?

Congrats on the green card! Not the easiest thing to get your hands on.

Legally, no problem for any medical provider (MD, DO, NP, PA) to give you a prescription for mesalamine, or any other drug that doesn't have some specific restriction (rare). If you bring in samples of what you use and explain that it is simply a low side effect maintenance medication, they should write a short term supply to get you through your insurance waiting period.

My recommendation is to book an appointment with a GI doc right away. GI is an in demand specialty and there can be long waits to get an initial appointment. Just book a time in the future when your insurance has become active.

I am a Canadian living in the U.S. on a green card, so I've been through it all.

Dealing with the healthcare system is a pain, especially if you have a chronic (and expensive to treat) condition like U.C. Drug prices are ridiculous but you can always get stuff from Canada if you are in a pinch.

It's not all bad though because it is much easier to see a specialist. MRI's, CAT scans, colonoscopies, and other diagnostic testing is readily available on short notice too.

For insurance you usually have a deductible which has to be met before coverage kicks in. If your employer offers a HSA or FSA (Health savings account or flexible savings account), it can help with the deductible.

Taxes are lower in general here, but a lot of the savings will be eaten up with healthcare costs, so in the end it pretty much balances itself out.

I would appreciate some help from Americans to understand how my future health insurance plan works and if it is any good.

My company is providing me with health insurance. It is a PPO, Regence BlueShield of Idaho. For a single, it has a $750 deductible and $3,000 out-of-pocket limit. Co-insurance for mos of the services by in-network providers is 20%, with a $30 co-pay for visits.
Generic drugs have a $10/retail prescription copay, preferred brand $35 and non-preferred brand $75.
For non-preferred brand, I must pay the difference in cost between the generic and the brand.

I am now taking brand Mesalamine MMX (Mezavant/Lialda), but I know already the preferred drug is the generic Lialda. According to goodrx.com, a one-month supply of the generic costs $500, whereas Lialda costs $870. So, if I want to keep taking Lialda, does it mean that I would have to pay $75+($870-$500)=$445? It sounds like it would be much cheaper than to order it from Canada.
Or is there a way for a doctor to convince the insurance that I need Lialda and not the generic and dispense it as a tier 1 drug?

Another question.
Considering the financial burden of UC, I am assuming that I will reach each year the out-of-pocket limit. It is not clear to me if, once I reach the out-of-pocket limit, every subsequent expense is covered 100% by health insurance or if I still have to pay co-insurance, co-pays etc.
In case I use out-of-network services, does the balance billing amount count towards the out-of-pocket limit? Do I still need to pay the difference in cost between preferred/non-preferred drugs and services once I reach the limit?


Thanks for your help. The healthcare system (business...) is really crazy and messed up.

iPoop said...
Regarding Lialda, you can try an appeal to your insurance company and some have success and others do not. They'd never call it a tier 1, a tier 2 at most... You could try the generic lialda, that would be the easiest and most affordable option. The math is tougher to guarantee, different pharmacies have different prices.

"once I reach the out-of-pocket limit, every subsequent expense is covered 100% by health insurance?" Yes, it is.

"I still need to pay the difference in cost between preferred/non-preferred drugs and services once I reach the limit? " No, you do not.

"In case I use out-of-network services, does the balance billing amount count towards the out-of-pocket limit?" Depends on health insurance policy. If you have a single deductible for both medications and services then yes. Some policies have separate deductibles for medical, separate deductibles for services, and they are tallied separately. In that case no.

Did you switch yourself from Lialda to the generic? Did your UC respond well to the change?
I am a bit worried about switching medication.

Do I need to go to a gastroenterologist to appeal for Lialda, or a family doctor can do that?

I am coming to the USA with a letter from my current family doctor stating that I have UC, the medications I am taking etc. Would this be enough to get prescriptions once I am in the US?

iPoop said...
I recently moved between states within the USA, and the process is similar. Before my move, I:
1.) Got a referral to a new gasteroenteroligist in the new state.
2.) Called the new gastero, asked what records they needed to accept me as a new patient.
3.) Had my old gastero fax/mail the requested records (meds, colonoscopy report, biopsies, a brief patient history) send to the gastero.
4.) Verified new gastero has received the above, and then and only then, they scheduled a new appointment for me. New apt was several months from the date I called.
5.) I moved and continued filling my prescriptions under the old gasteroenteroligist until my apt with the new gastero.
6.) Had new apt at new gastero and he gave me new prescriptions.
7.) New insurance in new state required different 5ASA/Mesalamines, new meds got at the pharmacy.
8.) I got a new family doctor several months after moving to the new location. Family doctors I find a whole lot less useful lol. My primary issues are GI-related, and the rest (fortunately) is a non-issue.

Moving is a true pain in the butt for us who need regular access to doctors, prescriptions, etc. Do your homework, search online for the nearest gasteroenteroligist office to the university you plan to attend. Call and explain your situation, ask what you need to do to become a new patient and get an initial office consultation scheduled. Get everything moving BEFORE your move, as it's easier to nudge your current doctors along to get your information transferred while you are still their patient than afterwards. Verify you've done everything needed

Thanks, this helps.

I will be moving to a rather remote area (North Idaho) and the choice is somewhat limited, especially it is difficult to find out if there are IBD specialists.

When scheduling the appointment, could they ask if I have insurance and for proof of it?
I am moving to the USA to start a new job (not to attend a university), but my employer plan kicks in the first of the month after 60 days of employment, leaving me uncovered meanwhile (except for those useless short term plans). Considering this, I was thinking of paying out-of-pocket the first appointment, but I have no clue of how much it could cost, even if I am expecting crazy amounts.

notsosicklygirl said...
If you're concerned about needing a doctor during those two months, I think I would ask them if they would consider letting you into the plan early, or consider buying your own plan through the ACA. The problem is that you will spend the monthly premium, and you will never get anything out of it since the deductibles are high, but at least in the case of a major health situation, you would have coverage. The other option is like you said, just pay out of pocket, but then if something happened and you were hospitalized, you would be without insurance. It really stinks that this is a consideration when you're moving. You should be looking forward to a change of pace, scenery, a new start, but instead, the health situation over here is so poor that you end up stressed about insurance. At least after the initial 60 days you're in good shape.

I only hit my out of pocket one year when I was hospitalized, and I had a fairly low limit (2500). That year, I paid for nothing else. Now, the plans seem to be worse, it's nearly 6k out of pocket, and I don't go to the doctor, so I have no idea.

I asked for an early entry into the plan, but unfortunately it is not possible.

I have asked the same insurance agent that manages the employer plan if I can enroll into an individual ACA plan. I can do that, but then apparently it's timing that doesn't work out for me. In fact, to buy an individual plan, they require proof of address (utility bill) and a state driver license, both to verify residency. However, since I am moving from a foreign country, it will take me a few weeks to find an apartment, get the first utility bill showing some usage, and to get a state driver license (I have to retake the driving test in the USA). Besides, plans start on the first of each month, so I would need to provide all these 10-15 days in advance. Basically, once I got everything, it could almost be time for the employer plan to start. The situation is absurd...

This is what I was told by an insurance agent. Could you confirm it works like this?

When I moved between states, as I proved I had insurance prior, the 60-day wait was waived.