Is there any possibility in the US to purchase extra health insurance to get coverage for a medication?
So we are going thru fertility treatment, specifically IVF, which involves multiple drugs.
One of the drug called Gonal-F is exorbitantly higher than any others in terms of price. It’s follicle stimulating drugs and there are only two manufacturers in the world, Merck and its subsidiary, so it’s basically Merck producing all of this.
Honestly, without this drug, IVF medication cost is not that big of the deal, but this is really a deal breaker enough that sometimes it’s better to look out for donation and take a working day off just to get the medication from the donor even if the donor is located within 5 hours of driving unless someone can make 1000-3000$ per each working day (and if so, then there really is no point of worrying about any kind of medical cost).
Gonal F dosage for 1 IVF cycle is generally speaking 300 IU per each day, and the recommended dose is 10 days. The price per 1 IU (unit) is 1$, so it’s basically 300$ per each day, and 3000$ for 1 IVF cycle that may or may not work (on top of excluding actual IVF treatment, because medication is only part of prepping body).
Recently, our medication cost reaches what’s called “Life time max” benefit, meaning that even if out of pocket maximum is reached, this drug cost is not gonna be covered because of “life time max” definition of chastising the benefits to patients.
So I did take a look at insurance claim, and they charge 3$ per IU, instead of 1$ per IU, which is out of pocket price. Now some specialty pharmacy offers 1$ per IU if it’s paid out of pocket, but when it’s going under the insurance, it’s charging 3$ per IU, by which life time max benefits will easily be reached out.
This makes me wonder 1) why this kind of practice is even allowed to, and 2) what’s the real cost basis for insurance company to procure the medication.
Specifically, why some specialty pharmacy can provide it at cheaper rate than gigantic insurance company’s (i.e CVS specialty pharmacy) can offer? If anything, my common sense is telling me that big company such as specialty pharmacy should have better pricing power, but perhaps, they are always maximizing their profits as well?
Just curious to learn their game so I can better understand!
Thank you
