Why Are Medications Priced Differently Now?
Question: My new doctor says that my Prolia shot will be very expensive. When my previous physician gave me the shot it was covered in full. Why the difference in cost?
Answer: Vaccine and injections prescribed by our physicians are covered differently depending on what the injection is for. Original Medicare Part A would cover any injection given as part of a hospital stay. Medicare Part B covers outpatient services including some injections and vaccines; the Flu shot, Hepatitis B, Pneumococcal and COVID-19. These vaccines are administered either in a doctor’s office, health clinic or pharmacy and are covered in full by Medicare Part B with no deductible and no 20% cost share.
Some injections are covered differently based on where you get them, and why. Tetanus is one example. If you receive a Tetanus shot as a response to an injury, the Tetanus shot administered to you would be covered under Medicare Part B. If you receive a Tetanus shot because you haven’t had one in a long time (more than ten years) the injection would not be covered by Medicare Part B. Your physician’s office would be considered out of network for this billing- because the office is not a pharmacy. Instead, you would have to file a claim to receive reimbursement from your Part D plan. That reimbursement would be based on using an out of network provider, and would therefore reimburse you a lesser amount than the retail cost.
A Second example covered under Part B or D is Denosumab (brand name-Prolia). Denosumab is an injection that you get once every 6 months. This injection coverage is based on who orders it and how they order it. Some physicians order the medication through their office (like a chemotherapy drug) and therefore it is billed under Medicare Part B coverage. In this situation the office has to pay for the medication and wait for Medicare to reimburse them for the medication and the administration. Most physicians are unable or not willing to carry this financial burden and responsibility. Those physicians order the medication for you at your pharmacy, you pick it up and bring it to the office to be administered and it is therefore a Part D medication and goes to your Part D insurance plan. In this second scenario, the Denosumab injection is considered a 6 month supply of the medication. The insurance company cannot bill you for 6 co-pays, so you actually pay the three month supply cost structure. That could mean a significant cost for the injection even when you are in coverage. To help illustrate; The Denosumab shot retail costs roughly $1300. So the deductible could be up to $505 and then it would move into the Initial Coverage and the cost is based on the Tier (usually Tier 3 or 4). This cost could range from $42 to 33% ($429) in most of the plans. That is a big swing in price depending on your plan. This injection is also a multiple month’s supply, so you could be charged up to three months of co-pay for that single injection. ($42×3=$126 or $429×3=$1287). In the coverage gap the cost structure changes to 25% ($325) and during catastrophic cost it moves to 5% ($65). These 25% and 5% would be filled as a multiple month supply and the cost would be three times this amount.
Other immunizations and injections that are covered by Medicare Part D include vaccines like shingles, MMR (measles, mumps and rubella) and DPT (diphtheria, pertussis and tetanus). In this situation your Part D plan would place these medications into a tier (1, 2, 3, 4, or 5) and the phase of coverage (deductible, initial, coverage gap, or catastrophic) you were in would determine your cost share.
If you have a Medicare Advantage Plan your immunizations/injections are covered, but you might not be informed of how it is being covered (outpatient vs pharmacy). The insurance company would file it into the appropriate type of coverage and your co-pays structure would follow the protocols of your Medicare Advantage Plan. If billed as Part B coverage they could cost 20% of the retail price. If Billed as Part D it would fall into the phases of coverage and Tiers your Medicare Advantage plan defines.
You also may have EPIC (Elderly Pharmaceutical Insurance Coverage) which would be secondary to your Part D plan. This could help cover the cost of immunizations and injections billed via your Part D coverage.
For your Prolia injection, you may want to try to find a provider (likely a specialist) who will bill it as your previous physician had, to your Medicare Part B.
Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email SLM@lutheran-jamestown.org.