I assume they are bedded with specific pharma companies - and those are promised first dibs. :)

I've been really affected by this - insurance company dictating the use of a different med than the one that previously worked for me.

My theory is the insurance companies make pre-arranged contracts with certain drug manufactures and get a discount if they agree to only authorize the use if said drug. And even though the billed price may look the same, I'm sure there are kick backs just like about every other industry.

An example of this -

Humira every other week $2654
Enbrel every week $2690

So why else would they demand the Enbrel over the Humira?

Oh - and forgot to mention - thanks for posting that! Very interesting facts - bookmarking it to read in depth tomorrow.

While skimming through it, I picked this up which really helps me understand more - a fact that I didn't know:

Biologic Effectiveness - 25 to 50 percent of people who take biologics can expect to experience at least a 50
percent improvement in the number of swollen or tender joints.

So basically that tells me that only 1/3 of the people on biologics will see 50% relief. Not very promising but puts things in perspective for me.

My own checkbook doesn't make sense to me often so I'm not even going to try to make sense of my biologics costs (especially since I can't figure out why my Xeljanz costs so much and it's a pill - shouldn't quality control be much easier and production cost less?!? I know shipping has to cost less as it doesn't come in a multilayer temperature controlled box! But I digress...).

I do want to thank you for posting this depotblue as it was a very interesting read. Definitely lots to digest. LOL Besides it gave me a warm fuzzy that my next one to try - orencia - is a good one from this study. ;-)

Very interesting! Thanks for posting this!

This is a strange article. They start by saying that MTX and other DMARDs are as effective as biologics. HUH?? They say that bios don't slow disease progression, then say they do. Alrighty then. The numbers in Table #3, looking at effectiveness and discontinuation because of side effects, vary really widely: 24 - 97% response rate to Humira? 100% for Enbrel? Whose study was that?

Kineret is the cheapie, along with a couple of the less-used infusions. Anyone around here ever tried Kineret? You'd think the insurance companies would be pushing it like popsicles on a hot July day.

I guess what I find strangest is their perceived need to do this article at all. Consumer Reports is the go-to source when buying a new washer & dryer or choosing a brand of detergent or vanilla ice cream. I'd love to see the look on my rheumy's face, though, when I tried telling her I wanted the bio that CR recommended!

I'm curious as to where they got their numbers for pricing. Does a huge outfit, like United Healthcare or Kaiser get a better deal than my smaller company? Does BC/BS get a better price if they can keep over 20,000 patients on, let's say, Humira? Some of us have had one drug denied that someone else was forced onto when their first request was denied. Odd, odd, odd.

Alto,

i put it in solely to look at pricing costs with a lead caveat that I understood, probably that, pharmas negotiated specialty pricing discounts with insurers, ,probably but with an overall interest in the cost relative to the pain and suffering some folks were having with decisions being made by their insurers. I am thinking that in 2012 or forever this magazine does not take advertising. that's kind of a good thing...in terms of getting pricing. the magazine was not pricing out the same stuff it could be advertising, prose or journalism wise.

i did not put it in for the science of it. i thought my lead in said see page 9 of the PDF.

pass the baton for the DS hole, my turn to crawl in.

Depot

No, no, Depot, no holes to crawl in! This wasn't CR's review of kale varieties!

I'm just curious about why they've chosen to look at prescription meds at all. I agree that they wear white hats. As you say, they don't accept any advertising dollars, and I've never heard any reports of bias or crookedness on their part at all.

I'm curious, when none of us really have much say in what we take, between our doctors and our insurance companies, why they would spend the time on high-powered, high-cost prescription drugs. Not that they shouldn't: the more information we have, the better off we are. OTC allergy meds, we have more choices in what to buy.

I couldn't find a source for the price info. I'm sure, like most things medical, the price quoted as "retail"- what an uninsured soul would pay, cash- is not what the insurance company pays.

How many of us have an idea what our insurance companies are paying? I know my Orencia comes with info that it was just under $2500. I want to say my Humira (different, much larger ins. co.) was around $1800. I assume these are before what the copay assistance plan kicks in. Anyone else?

I get my Cimzia from Wal Mart specialty pharmacy and they bill my health insurance $3,256.52 for a 28 day supply.
My health insurance pays them $2,765.22 (maximum allowed).
I pay a $44.00 co-pay.

Thank you for sharing.
Very interesting & informative. I've wondered the same. Why one med is approved/covered over another?
Well I have to agree with Alto. There's seems to be a trade off between companies. So I'm sure most struck a bargain.
Much like limiting or dictating which pharmacy you can use. Speciality or in cases like mail order. I have no choice the insurance tells me who I must use.

Certainly not thrilled that my insurance insist I use the bio with the most side effects (according to consumer reports)
Seems that would drive their cost up in medical care.
Makes no sense to me at all. If I was on the board of an insurance company I'd sure consider secondary causes of driving the medical cost up. Then again not much makes sense with medical coverage.

Again thank you for sharing. Sure helps me to keep Orencia top of the list if Cimzia fails. Also prompts me to ask my dr a couple questions.
Sammy

I have no clue about the insurance's meddling in the protocol for their insured patients, but there definitely is some.

My question is why are the biologics so darned expensive, but seems most of them have a patient program that after the insurance pays their portion, the rest of the cost is absorbed by the drug manufacturers so that the patient's co-pay is $5.? So it seems the drug manufacturers are stinging the insurance. I may have just answered my own question.

-daizy8

I'm on BCBS and they stopped paying for enbrel too. I was in remission for 4 years. Now I take Aleeve and Vicodin. I can't Sgtord Enbrel . I get it again in Jan and Feb and so I stretch it over one year.
My pharmaceutical benefits are only $5000.00 a year so I run out very quickly. Enbrel pays 1/2 and ins picks up the rest. I also pay $ 410 .00 a month premium. It all sucks. The only good thing is that when I get Enbrel it goes towards my deductible and after I met that all my dr visits are free. I only pay for meds.
Anybody have better ins let me know, I'm ready to switch.
Bigiblue

Interesting. Actually, I read this article a while back and it doesn't add up to anything useful. First, doesn't everybody here know that we all react differently to meds. Yes? And, doesn't everybody here know that most of the biologics fall in the same category for treatment mechanism: ie, anti-TNF. So, here's another factor that may have been asterisked (shoot me if that's a real word): some drugs require a "clinical" setting for administration. You can get Remicade, and I think Orencia, in your Rheuy's offic, but Rituxan requires a "chemo" setting. Trained nurses, close to doctors, etc. The "billed" cost can run $160,000 or more per year. The actual cost will cary, depending on what kind of contractural agreements exist between the insurance and provider (outpatient chemo clinics), but in the neighborhood of $85,000 per year.

We should have nationalized (ie single payer) insurance system. I won't get into the politics.