Navigating Costs and Insurance for Rituxan (rituximab)

Lisa Emrich Health Guide February 22, 2010
  • As you have been following my Rituxan story, I have been sharing information about my personal experience in receiving this infusion medication for RA, any reactions I had to the infusion (see part one), and any benefits I’ve seen from the infusions (see part two).  This month I’d like to share the expenses involved.

     

    Like many of us, I like to know the cost of something BEFORE I commit to purchasing.  After receiving the ‘go-ahead’ from my rheumatologist and my neurologist for starting Rituxan treatment, I needed to find out what my out-of-pocket costs were going to be and find a pharmaceutical assistance program to help with those.

     

    My first homework assignment was to find out which hospitals my insurance company would pay for outpatient infusion therapy and to discover if I needed a chemotherapy preauthorization ahead of time.  A call to the insurance company came first and I was pleased to discover that each of the local hospitals were equally satisfactory to my insurance company.  No preauthorization was necessary.

     

    Then I discovered The RITUXAN for RA EXPERIENCE Program which provides eligible patients with $4000 per 12-month period in direct assistance to reduce the out-of-pocket costs of Rituxan.  To apply I called the 1-888-697-4889 number.

     

    While on the phone with the program representative, I asked about the cost of Rituxan itself.  She didn’t know and suggested that the price was affected by insurance negotiations.  So I called my insurance company again to ask the same question.  With a 10 percent co-insurance, I wanted to know how far $4000 would go in covering out-of-pocket costs.

     

    After a few more calls, I was quoted a cost of about $560 per vial (10 vials are required for infusion).  Turns out that what my insurance paid the hospital was 75 percent higher than the price I was originally quoted.  Yikes.

     

    I don’t have an answer as to why the big difference, but 10 percent of $9800 is a whole lot more money than 10 percent of $5600.  I'm so thankful that I could use the assistance program and that I don’t have a 20 percent or even 30 percent co-insurance requirement.  Can you imagine?

     

    To enroll in the program, I needed to sign and have my doctor sign a release form.  Genetech/Biogen needed to make sure that I really qualify and have RA I suppose.  The facility at which you receive your infusion is also supposed to enroll in the program, but fortunately there is a workaround if that is not the case (as in my own case).

     

    My infusions were done in a hospital outpatient center and on the day of the 1st infusion I told a nurse that this program needed the hospital to enroll and the program needed to know the lot number on the vials of Rituxan.  Of course, none of this was accomplished on that day so I called the assistance number while sitting in the hospital bed.  I was told that after I received the hospital bill and my EOB (Explanation of Benefits) that I could fax her the information and they would send a check to the hospital (or me).

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    So I waited for the EOB and hospital bill, the EOB arriving first.  The hospital had billed $17,784 for the first infusion.  Insurance ‘allowed’ $11,559 of that and discounted the rest.  Insurance paid $10,476 and my responsibility was $1,082 (not perfectly 10 percent but you will see why soon).  I awaited the hospital bill and hoped that it gave more detail as to how much of the cost was the drug alone.

     

    When I received the EOB for the 2nd infusion, I discovered something exciting.  The 1st infusion had fulfilled my out-of-pocket costs for the year according to my insurance coverage.  That had never happened before.  The 2nd infusion was completely paid 100 percent by insurance.  Very exciting!!  I almost feel guilty...only a little, and definitely giddy.

     

    Since the hospital bill didn’t give any detail and the EOB only gave some detail, I needed a complete breakdown of the charges involved.  I needed to know how they came up with $17,784 and $17,487 for the two infusions and send the proof and details to the RITUXAN for RA EXPERIENCE program.  A trip to the hospital cashier gave me my answers.

     

    The cashier called the program representative directly and took care of the necessary faxes on the spot.  Fortunately I had taken copies of my EOBs and hospital bills with me on that day.  The hospital should be getting a check on my behalf soon.

     

    So here are the costs involved in receiving two Rituxan infusions (one full round of treatment).  Please note that your hospital/rheumatology clinic may submit different charges and your insurance company may cover those charges in a different way than mine.

     

    First Infusion of Rituxan on 11/19/2009:

    • $ 15,023 - Charge for 10 vials of Rituxan
    • $ 81.20 - Charge for other pharmacy (Tylenol, Benadryl, Hydrocortisone)

    Insurance allowed $9817.72 for the above and paid $8835.96

    • $2510.40 - Charge for six hours of Infusion Service ($1631.76 allowed)
    • $  169.50 - Charge for three IV pushes of drug (steroids, benadryl) ($110.17 allowed)

    Insurance allowed $1741.93 for the above and paid $1640.93

     

    Second Infusion of Rituxan on 12/3/2009:

    • $15,023 - Charge for 10 vials of Rituxan
    • $  79.60 - Charge for other pharmacy (Tylenol, Benadryl, Hydrocortisone)

    Insurance allowed and paid $9818.39 for the above

    • $2092.00 - Charge for five hours of Infusion Service ($1359.80 allowed)
    • $  169.50 - Charge for three IV pushes of drug (steroids, benadryl) ($110.17 allowed)
    • $     3.70  - Charge for Venipuncture (drawing blood)
    • $  119.80 - Charge for Blood tests (CBC, platelets, etc) ($19.55 allowed)

    Insurance allowed and paid $1493.22 for the above

     

    Total amount billed for one round of treatment: $35,271.70

    Total amount insurance allowed for treatment: $22,871.26

     

    UPDATE on February 22, 2010:

    Oh the irony of this post going up today.  I received a "Final Notice" from the hospital last week and immediately called them to see if the RITUXAN FOR RA EXPERIENCE program has paid yet.  NO, not yet.  The hospital is marking my account for one more month before turning it over for collections.

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    Today, I called the RITUXAN FOR RA EXPERIENCE program to ask if they've sent the check.  Nope, not yet.  They haven't cut checks yet this month.

     

    Then I wanted to make sure that the program really will approve the check.  DARN!!  They are not satisfied with the detail of the documentation submitted, although I've given them everything which is available to me from insurance and the hospital.  The itemized bill does list each drug - Rituxan, steroids, benadryl - but doesn't specify how much was ALLOWED and PAID for each of these, just what was billed.

     

    I call insurance in an attempt to get PROOF of the amount which is Rituxan vs. anything else.  The insurance representative I spoke with was very nice.  However, bad news.  Their records also don't split the appoved amounts down to that detail.  Imagine.

     

    I NEED PROOF!!  So the insurance rep is going to see if they can create a letter stating which portion of the EOB is for pharmacy vs. hospital and what is my co-insurance amount for each.  However, she still doesn't have the amount specifically ONLY for Rituxan. 

     

    I call Bettina back at "the program" and tell her what I've been told by the insurance representative.  Now, she seems thrilled and satisfied that the letter would be enough for approval.  I'm not going to hold my breath because it's still not going to detail the Rituxan separate from total pharmacy.

     

    When I originally wrote this post, I was excited that this program would really be as easy to use as the paperwork implies.  Ha!  I should have known better, having been through several assistance programs over the years; nothing is easy even when it's supposed to be.

     

    We'll see what happens in the end.  Hopefully this will have a happy ending before my hospital bill is sent to a collections agency.  I wonder if it would have been easier to just ask the hospital to forgive my portion of the bill since I'm technically earning about 150% Federal Poverty Level. 

     

    I'm ready to go crawl under a blanket now.  It's exhausting to deal with the financial aspects of living with chronic illness.

     

    Lisa Emrich is author of the blog Brass and Ivory: Life with MS and RA and founder of the Carnival of MS Bloggers.