The cost of Enbrel is insane, yet I pay nothing.

This post, like others that will follow it, is a continuation of my Gambling On Life series.

Last night I took my first dose of Enbrel.

Nothing about Enbrel has been particularly enjoyable thus far. While the medication itself so far is fine - I had no major reactions to my first dose, although I fucking hate that I have to basically stab myself weekly now - the entire process to get Enbrel makes me feel like I'm walking across a thin bridge without hand rails.

I had very little documentation on how this was supposed to work, so to start off with, I want to outline the core stuff you need to know if you're about to start Enbrel and are worried about how you'll pay for it.

First your doc will submit the prescription to a specialty pharmacy. Make sure it's in-network for your insurance provider; that's going to be pretty important, even if insurance doesn't outright pay for much of it.

Then you begin a really exciting song and dance. For me, they called me to let me know they recieved it. I wasn't ready to actually fill it yet, though: I had one important thing to do first.

I had to sign up for a payment card.

In my case, I first registered on the pharmacy's website so I could manage everything there rather than via the phone. I also went into the payment area, where they had a section for adding both my personal payment information and a payment card for payment assistance.

You need this because Enbrel is fucking expensive as fucking fuck. I'll talk about that later, though.

Anyway, they actually listed payment assistance providers on the site I could use, and I decided to go direct to the manufacturer.

Signing up for payment assistance didn't actually really require much; they don't care how much you make, what assets you have, or even require a sob story about how broken you are both physically and financially; All they wanted to know was my name, where I lived, and my insurance information, and BAM! Instant approval..

.. For $7.5k annually, and it resets at the start of the new year.

At first, I think to myself.. "Wait, that's not much. That's not even enough to cover 1 month of treatment. How in the fuck am I supposed to be able to afford this shit?"

Well, I decided to look at my insurance portal to see how much they'd cover, and saw something weird: My deductible was maxed out, as was my max out-of-pocket.

Now that $7.5k makes sense: That's my deductible on my insurance.

Enbrel is fucking gaming the insurance system; I had thought it was weird that Enbrel was willing to pay for some of my medication, and assumed it was some sort of way to game taxes or federal subsidies or something, but nope.. As it turns out, the game is being played on the Insurance companies themselves.

Anyway, with that worked out, I then did a bunch of back & forth between the specialty pharmacy and the payment card folks (pharmacy needed the effective date for the payment card, which I didn't know was the day I was approved), and then did a review of my current issues, medications etc with the pharmacist over the phone before I got my first prescription.

I also talked with the pharmacy about what will happen if for some reason insurance or the payment card doesn't cover everything, and what my options are.

Hint: There are no options. I'm on the hook for whatever isn't covered, and there is no refund policy.

Here's where I talk about just how much Enbrel is gaming the insurance companies for.

My prescription costs more than $2k per dose, and I take a dose a week. The total cost annually for this treatment is more than I make gross.

Even if I have to pay for just one dose myself is going to hurt me financially.

Thankfully, because my deductible and max OOP is instantly maxed out with just one month's prescription, I pay literally nothing..

..Assuming the insurance company doesn't get tired of how the game is being played and decide to rage-flip the table, because you know who's getting fucked there, right?

It's the patient.

This whole thing is just.. Absurd. If one part of the system fails, I get royally fucked. I'll have to monitor insurance like a hawk to make sure they don't deny coverage, because if they do, and the pharmacy sends out my prescription? I'll be on the hook for all 4 doses, which I literally cannot afford to pay for.

I can't imagine what would happen if someone wasn't able to stay on top of it, and ended up not realizing they were about to be financially ruined thanks to necessary medication and an overly complicated Rube-Goldberg device that is the relationship between pharmacies, manufacturers and health insurance.

I'm grateful I don't have to pay anything, but like the monkey puppet meme, I'm definitely glancing to the side to make sure everybody is still standing next to me in this whole song and dance..

Because if just one steps out of line, there's going to be a lot of hurting going on beyond my untreated ailments, and it's not going to be any of the corporations that are feeling the pain.