Herceptin costs?

Brenda_D · 03-19-2007, 11:47 AM

After receiving my insurance statement on my first Herceptin treatment, I found that my Onc is charging over $600 more than my insurance considers "reasonable".
Total charge for Herceptin dose was $3745.50 with a provider discount of $608.30, leaving me to pay the $608.02 difference.
I don't know about you but we can't afford $608.02 every 3 weeks.
I'm curious what rates you're being charged for Herceptin.
Is my Onc overcharging or is my insurance co. under paying?
All other chemo drugs have been paid for 100% by my insurance co.

LOPSIDED · 03-19-2007, 12:09 PM

MY ONCOLOGISTS ONLY CHARGES ME A 25.00 CO-PAY EACH TIME I COME IN THE OFFICE TO SEE HIM OR FOR TREATMENT. HE ONLY CHARGES WHAT MY INSURANCE WILL PAY FOR THE HERCEPTIN.

Mary Anne in TX · 03-19-2007, 01:00 PM

My insurance doesn't even pay as much as yours does. But I don't have to pay the difference on Herceptin.

It's the funnest (not so funny) thing though! My insurance Unicare, paid very little of my radiation treatments, so I am paying the difference there. Maybe just because it's the first of the year and I have to pay the first $5000.

I know there are strengths and downsides to all the insurance companies, but then it's a little late to switch!!!

Sheila · 03-19-2007, 01:44 PM

Brenda

If it says provider discount, that sounds like a PPO discount, as that is what mine says and I DO NOT have to pay it...I don't even have a copay...but then again, I am being charged 9,988.00 every 3 weeks for 384mg of Herceptin....and that doesn't include the pharmacy supplies and infusion fees....and mine has been reduced! Mine used to be 12,000 every 3 weeks.....check with your ins. as the provider discount is usually not your responsibility!

After being on it for 4 years...I feel like the million dollar lady!!!!!

mts · 03-19-2007, 02:05 PM

I agree with previous posts... what your doctor gets reimbursed is what he contracted when he signed up to be a provider for your insurance. As long as the onc is a provider within your network... You should not be responsible for the overage. Have you met all deductibles...? It may even be an old bill. Check with your ins carrier and ask for an E.O.B. that has been paid to him and ask if you are responsible for any of those bills.

Maria (MTS)

Mary Jo · 03-19-2007, 02:05 PM

Yep, I'm with Sheila. A PPO discount is what is deducted from the cost of the treatment or whatever as a "deal" set up with the hospital, doctor etc. That cost is not pushed down to the patient.

Example, I had a PET/CT scan the end of Dec. The cost was 5600.00. The PPO discount was 1555.00. The hospital gets a check for 4100 and I am not charged for the 1555.00. It's just how it is arranged with the hospital for services under that insurance contract and using network doctors etc.

Hope you are NOT charged that exuberant amount of money.

Mary Jo

Brenda_D · 03-19-2007, 02:39 PM

Sorry, I should have been more clear in the first post.
My Onco is part of my insurance HMO. According to my benefits schedule, they should pay 100% except for a $15 co-pay for doc office visit, and $200 deductable for the year.
I met the deductable in Jan. with other doc visits and port surgery.
The first chemo bill came to $5087.82 with $3745.50 of that being Herceptin.
The first bill submission was denied pending "large case management rates".
After they reviewed the bill, they show a "provider discount" which is what they allow to be paid per their contract with the doc for being in the HMO network. The full price is what I would have been charged if the doc was "out of network".
The charge for the Herceptin was $3745.50 full price, and they show a provider discount of $608.30, meaning they allow the doc to charge $2529.18 for the Herceptin.
Since he charged me more, that leaves me owing him $608.02 for one dose of Herceptin.

My insurance is 3 tier, with HMO, PPO and out of network options. I can choose any, but HMO is supposed to be paid 100%, PPO is 90%, and OoN is 70%.
Where it gets sticky is that the chemo drugs are considered as medicine/pharmacuticals, and I guess he doesn't have to charge the "contracted" rate for meds.
I'm tending to thinking they charged that amount to recoup the "discount" on the Herceptin.
Anyway, this is not good news, and I hope the doc doesn't end up charging me the extra cost, because I won't be able to continue at that rate.
I am checking into getting him to write me a script and get it filled at mail order pharmacy that my insurance co. contracts with. If I can do that, then the insurance should pay it all, or I may have a small co-pay.
My insurance co said the onc can order it from thier pharmacy and get it at a reduced rate and I would only be charged what they cover. Meaning I would have no cost.
But the Onc isn't inclined to do that.

edited to add- this isn't an old bill. Up to now we've been able to keep everything paid up.

Barbara2 · 03-19-2007, 07:03 PM

We were charged $1200 for weekly herceptin. We had to pay our deductable; then the insurance paid the rest.

03-19-2007, 07:27 PM

Brenda,

Is it really possible that your doctor could order the drug in another way that would save you this money and he (or she) refused. Can you change doctors to one who actually has a heart. So far my insurance company has paid 100 percent of herceptin and chemo costs, but I'm enrolled in a Medicare HMO. You might considering calling the drug company to determine if it will cover some of the costs. My heart goes out to you--dealing with cancer and then this.

Melinda · 03-19-2007, 08:03 PM

Brenda,
I had insurance difficulty too. I have a BLUE CROSS PPO that gives me a 20% responsibility on ALL chemo drugs. I fought with my ONC who insisted that I could not afford the chemo, which infuriated me. She kept insisting that I would be responsible for 20% of all charges under the contracted price of the IV drugs and radiation. I looked at what they charged me for the first course and saw a $28,000.00 charge. Iamgine my expression and hysteria! What she failed to see on my insurance policy was that I have an out of pocket maximum of $3000,oo per year and an unlimited lifetime benefit. I do not know why she did not recognize this but for over two weeks, we fought about it. I called my insurance carrier who told me that after my deductible and out of pocket had been met... they would cover 100%of all charges at the contracted price and I would not be responsible for any other charges. Go over your policy again... I am not familiar with HMO but would not be surprised if they did not have the same clause.
WHile I was fighting with the business office of my ONC, she did tell me that after the "write off/ adjustment " that the office would make based on what the insurance company would pay... my portion would be (20%) $1500.00 be course of chem and that included herceptin. Which means that the total charge paid by insurance would be 7500.00. I will know more when they pay for the herceptin charge to give you an idea of what the insurance company pays.
Reread your policy and last but not least there is a book that you can download on line... here is ther link... its called BREAST CANCER COVERED OR NOT> AN INSURANCE HANDBOOK http://www.pabreastcancer.org/insurance_book.html.
Hope this helps, youcan download this free!
Melinda

Joe · 03-19-2007, 08:05 PM

Genentech may be able to provide some assistance, I suggest that you contact them via this link:
https://www.spoconline.com/spoconline/index.jsp

Regards
Joe

rinaina · 03-19-2007, 08:09 PM

I too only pay a copay of $20 each office visit and haven't had to pay anything once my deductible has been met. I have a ppo with humana. My onc has never asked for any difference between what the insurance covers and what it doesn't.

Bev · 03-19-2007, 08:31 PM

Somewhere on your EOB, it should say patient responsibility $.
All plans are different, but my chemo wasn't grouped with prescription drugs, but with medical treatment, as far as the deductibles go.

Read your policy and call customer service often. My guess is that you will eventually be covered past your deductible. If not, I would agree calling Genentech would be worthwhile.

Good luck, BB

Lani · 03-19-2007, 11:19 PM

Herceptin must be kept within a very narrow range of temperatures at all times or it becomes ineffective. It is delivered in refrigerated trucks and has to be refrigerated immediately. The cancer center/hospital/oncologist must have monitoring of the temperature of their refrigerators with persons available to come in on short notice if any of the refrigerators fail/power outage occur, etc or the medicine becomes ineffective. I have suggested that they should put a "smart chip" on the top of every vial of herceptin in order to be certain that it has never been outside that narrow range of temperatures before it is mixed to be infused--unfortunately there is the "political" problem of who would absorb the cost of replacing the spoiled drug, which seems to be what is keeping this option from being considered by the drug companies.

If you are considering ordering herceptin from an internet pharmacy, be aware that it might not have remained within that narrow range as they are not the usual distributors of these drugs and you would have no way of knowing it. Just my two cents worth...

kk1 · 03-20-2007, 07:14 AM

Brenda;

Before you panick make sure you understand your HMO policy benefits. eg. the relationship of copays,deductables, co-insurance, and max out of pocket.

For example I have 90% benefit with a $250 per year annual deductable, and a max out of pocket of $2500.

The 1st time this year I went for my 3 week herceptin I had to pay the $250 deuctable plus 10% co-insurance, total deduct plus co-insurance was ~$800. After 3 more round of herceptin ($600each 10% co-insurance on discounted rate) I reached my total out of pocket of $2500 and then they pay 100% of all procedures and chemo drugs. That is to say that the most it will cost me annually is $2750 out of pocket.

watch your EOB carefully as I have occasionally had the HMO make an error and only pay the 90% even after I had reached the max out of pocket. A quick phone call/appeal usually fixed the problem.

KK1

sassy · 03-20-2007, 07:47 AM

Please check on that bit about getting the drug elsewhere. All my chemo drugs were considered "treatment" and not on prescription side of my PPO, so they were paid at 100%. I was getting Neupogen shots and checked into getting them as a prescription to bring home with me to have administered by a private nurse, saving me a two hour trip each day after treatment. My onc was ok with that, but I found out that by taking it with treatment by the onc, I paid nothing. If I picked it up as a prescription, I paid 20%, plus anything over my $3,000 cap on med. SO--one shot would have put me over my cap and paying full price, $around $2500. Needless to say we drove back down the next day to get the "Free" shot.

Also, do you have a maximum out-of-pocket cost per year? If so, once that is met you pay nothing. Check with your broker, or your Human Resources person at work if the policy is thru an employer.
________
SabrinaCutie

CPA · 03-20-2007, 08:09 AM

This might be a billing/coding issue. Since you are receiving treatment every three weeks, not every week, you are receiving a larger dose (more expensive per dose). When the insurance rates were calculated, they may have been calculated at the weekly dose rate.

You may have to talk to somebody relatively high-up at the insurance company to find this out (most of the first level customer service people will have probably no idea what you are talking about).

I could be completely wrong with this, but it is worth looking into...

suzan w · 03-20-2007, 08:35 AM

I discovered, through all my treatments, that along with the "annual deductible" I also had a yearly "out-of-pocket" expense that I had to meet...I have WA Blue Cross. I only paid my oncologist a $20.00 co-pay for my herceptin visits (and I saw her every 3 weeks) but my "annual expenses"...ouch! Worth every penny however!!! Good Luck!

Malena · 03-20-2007, 09:51 AM

Fortunately in Italy the sanitary system is free! I know that every infusion of Herceptin costs around 1000 euros.

swimangel72 · 06-25-2008, 08:37 AM

Wow - I'm glad I found this thread! I'm in the process of switching oncs to save a long drive. Next week will be my first infusion with his office. Much to my dismay, his office manager called me this morning and said I'll owe them $80/month for the Herceptin and $80/month for the Navelbine! When I said why - that my old onc didn't charge me anything and all the drugs are the same AND they both take my insurance, she said they would cover the Navelbine charge but I'd still be responsible for the $80/month for the Herceptin (my Navelbine is only needed for an other 2 months - I'll have to continue with Herceptin every two weeks until April '09.)

I smell something fishy with this new onc - so I told them I couldn't afford to pay this monthly fee. Lo and behold, I get a phone call back and the manager tells me she contacted the pharmacy they deal with - and the recalculation is $60/month Herceptin and $40/Navelbine, but the Pharmacy will waive the co-pay since I said I can't pay it. I told her thanks - but that I was still surprised that they are billing through a pharmacy - why would they since this is part of a treatment? She said it's because of the reduction in Medicaid payments, and how all insurance companies are reducing their payments, so they need to recoup this way. I told her OK - but I hope half-way through the year they don't change their mind and hit me with a big bill, but she said no. STILL......I'm going to research another onc close to my house and see how they bill for the treatments. I have a bad taste in my mouth now and need to get rid of it with more research! Yuck!!