I've gone through the approval process with Blue Cross, waited for the TB test results, and now I'm just waiting for them to send my Enbrel.
The pharmacy just called and said I've been approved for 100mg / week for initially 3 months, and that my copay would be $791.
$791!!!! Good grief, there is no way that I can do this! And I'm sure that I won't qualify for assistance as I have a good job. But I sure don't have that kind of money sitting around.
What do people DO???

Suzanne,
Have you double checked your company's policy yourself? My policy is capped at a certain dollar amount, so my co-pay was only $40 a month. The catch was I could only procure 1 month at a time.
Good Luck!

With my Blue Cross insurance, once I spend $500 in one year on prescriptions the rest are at no charge. It's something to look in to. Luckily, my copay is $30 a month, one month at a time.
How much is a shot worth?

:( :eek:
You might want to give Enbrel a call. A couple of years ago, they were able to help Sue (beachbound) significant lower her Enbrel related co-pays by arranging to have her prescription filled by a mail order pharmacy. Here's the links to the threads where she describes her experience:
;
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I hope this helps.
Mike

Suzanne,
That sounds to be like you have a 50 % co-pay. I'm looking at a recent scrip for my enbrel and the total cost for 4 50mg shots ( a one month supply) was $1457.49. I also have bc/bs of California and on my plan ( PPO)the most I have to pay is $100.00 per scrip. That co-pay is high compared to others.
Do you get your insurance through your workplace? Perhaps they offer different plan options at different costs. This might be another option for you.

Yes, my insurance is thru work, and I just asked HR to pull a copy of the coverage. It states "...... self-administered injectable drugs, except insulin, 30% of the negotiated fee (subject to brand name prescription drug deductible if applicable." .........."Certain high cost drugs (injectable, infused, oral or inhaled) are obtainable only through PrecisionRx Specialty Solutions." There is a max out of pocket of $1,750 per year, but I think that only is for medical, not prescriptions. Mike, I'll give Enbrel a call, but this already is through mail order pharmacy. I think I'm out of luck!

NL, if my math is correct........... $792 copay = 30% of $2636. At 2 shots per week, that's 8 shots per month. $2636 divided by 8 = $329 per shot.

I am so sorry to hear this. I don't know how they expect people to afford this! I have GHI and our copays for Enbrel are the same as with any other drug.

The pharmacy just called and said I've been approved for 100mg / week for initially 3 months, and that my copay would be $791.
.........."Certain high cost drugs (injectable, infused, oral or inhaled) are obtainable only through PrecisionRx Specialty Solutions."....
Your first post mentioned "a pharmacy" and your second post mentioned the need to use PrecisionRx Specialty Solutions...is that the pharmacy you are using or did you drop the Rx off at a local pharmacy?
I know that my insurance (Humana PPO) gave me a similar co-pay if I was to use a local pharmacy, but if I used Specialty Rx (a mail order pharmacy) my co-pay dropped to $30/month.

I would call Enbrel's Enliven Services. They are SO, SO helpful! Call 1-888-4-Enbrel. That copay is just crazy. I even think they have an option for people with insurance questions.

Join the club! I just picked up my Enbrel today and my copay was $685.72!! I need to reach $2500 in prescription copays before my ins. will cover all. But for me, Enbrel is worth every penny!! Summer clothes, here I come!!

I called Enliven. They took all my insurance info, and said that they will contact the insurance company and my dr. for me, and that they would get back to me within 24-48 hours. I also called the company who administers our insurance plans at work and she is looking into switching plans for me. It just so happens that May is open enrollment for us, and the only month out of the year that we are allowed to switch policies. I also called my dr., and left her a message regarding the copay, and they are going to look into it as well. If I can think of anything else, I will try that as well!!! It just doesn't make sense, when I read that others are paying the standard copay, and the fact that I have never paid more than a $20 copay with my insurance before. And yes, this is through the mail order pharmacy PrecisionRx Specialty Solutions. With any high cost medicines, Blue Cross (at least my HMO plan) requires that you fill the RX through PrecisionRx Specialty Solutions. Thanks to all for your help - at least I will know that I tried everything I could!!

I am a teacher and I have BCBS State Employee. I was on Embrel from January until May and the copay was $50 for a months supply. The rhemy switched me to Humira which is normally taken once every two weeks, but my Doc put me on it every week and the copay is still only $50.
I hope they get your copay down to what it needs to be. Good Luck.
Cindy

I wonder what their criteria is for determining a "high cost drug"???? I'm currently taking Soriatane which is about $500 a month (and my copay is $20). Personally I would consider $500 high cost, but I guess they don't, as I can have that filled at a regular pharmacy!

The rheumy wanted to start me on Enbrel, but the insurnce copay was very high (500 per month) With a bit of research, I found that the insurance would cover Remicade at 100% and the Rhuemy was very happy to prescribe and administer. The sad part is that I work for the government and our insurance is supposed to be very good. Perhaps a bit of research would go a long way for you too

Part of the problem with injectables of any kind other than insulin is that many ins plans consider them therapy/medical,not just as rx's. sadly that can mean much higher copays if it is something you inject yourself rather than a treatment done in the dr's office. Almost all of the biologics are considered specialty drugs by a great number of insurance plans. Not that it will help right now,but,in another year or 2 you will see the co pays go down for these as well.
Just a note on the zyrtec co pay. Ins companies look at the drug class and what's available. Now that claritin is otc,the zyrtec and allegra co pays have gone through the roof. On the bright side. If it works for you,Allegra has a generic available now. Fexofenidine.

Not good news............ first I found out that the $1750 max out of pocket per year only covers MEDICAL expenses - there is NO cap on prescription copays. So, $791 x 12 months = $9,492 per year. Yikes.
The Enbrel folks called me back to tell me that they had in fact verified that it would be a copyay of $791 per month. Okay, I knew this............! They transferred me to the dept that helps with underinsured or non insured. I gave them more info, and even with my job / income they thought that I might qualify for something. However she said "I don't want to get your hopes up....... we have had so many situations like this that we're running out of money. The maximum per person for psoriasis / psoriatic arthritis is $1400." Well, that would be less than two months.
Not sure what I'm going to do now. It looks like my only option would be to switch insurance plans - and the only plan that might give me coverage for Enbrel would be Kaiser. I would then have to go throught the whole procedure of switching doctors, etc. No guarantee that I would have Enbrel prescribed either. I have PPPP on my hands and feet, and right now (it's a bit ironic, but I am thrilled!) the Soriatane is working really well. Not sure if it's temporary, but it looks the best it has in years and a new doc might not see how bad it was a month ago when I could hardly walk on my darn foot. So I'm not sure WHAT to do.

This will be a small comfot. Please dont forget that if you are itemizing, all medical expenses is tax deductable. This of course will not apply to everyone. Just a thought.

hi stillworking and nomobties,
welcome to the p family. you have met some of the wonderful people on here and will find alot of great info. welcome and nice to meet you.
have a good day all
richard

SusanneT
I have a 25% copay with the original dose at 100mg a week, somewhat similar situation. My only recourse is to do only 1 50mg shot a week and pay 328.00 a month. I cannot afford the 100mg at 656.00.
Anyway the one shot a week is working and I have cleared up, I still have the discolaration where the P was but I am wearing short sleeve shirts and shorts again, I am almost human.
My insurance stinks but I am glad to have what little I have. When I was on 100mg my system was doing weird things, also got a few infections so I am satisfied with the 50MG a week.
I did get a cold a little bit ago and I did not go off the enbrel, the last time I was on it I was doing 2 25 MG aweek and got a cold and went off it and some of my P came back and stayed. No matter what, I am going to stay on it. Hope this helps a litte bit, 50MG a week is better then none and you save a little money. To bad it has to be so exspensive. They just don,t know what we endure. Peace be yours

Suzanne,
I was on an Aetna plan and was paying $136/month for Enbrel (supply of 4 SureClick pens), but my company recently switched to United Healthcare (a nationwide provider) and now I'll only pay $40/month. So there is coverage out there. Don't be discouraged.

Just a thought for you. I'm not sure what you've tried or haven't. I'm on Remicade and since it's an infusion not a prescription it doesn't go through my prescription coverage. All I have is a specialist co-pay for each infusion. It may fall under your medical cap.

I am the caregiver of a beautiful aunt who is depressed because of the Psoriasis she has over her arms and legs. She has medicare insurance(SSI) This is all new to me so I am doing research. I dont know if this insurance will pay meds like Xtrac, etc. She has had this for years and she said the doctor has just giving her cream...Now this is all over her both legs and both arms. would you know what I need to do to help her.

I am the caregiver of a beautiful aunt who is depressed because of the Psoriasis she has over her arms and legs. She has medicare insurance(SSI) This is all new to me so I am doing research. I dont know if this insurance will pay meds like Xtrac, etc. She has had this for years and she said the doctor has just giving her cream...Now this is all over her both legs and both arms. would you know what I need to do to help her.
Hi Jalapeno2238!
Welcome to the Board. :cool: Nice to meet you. Thank you for being there for your aunt. :) I'm sorry to hear that she's going through such a rough time. :( I just posted a copy of your introduction to us in a brand new thread. (Here's a link to it: .) I figured that you'd get a better response that way. (I'm going to be sharing some additional thoughts, that hopefully will be helpful to your aunt in the thead that I started.)
I hope this helps.
Mike