A 37-year-old woman got an $18,000 charge for her fertility medications — and it reveals a disturbing problem for the US healthcare system
- Andrea, a 37-year-old woman going through egg-freezing, faced an $18,000 charge for her
- The amount would have used up most of the $20,000
fertilitybenefit she had with her employer.
- After a stressful process of arguing with her insurer and the
pharmacyshe used, she found that if she paid in cash she'd be expected to pay only about a third of that amount.
- Andrea's experience is one that patients in the US often find themselves in: dealing with a medical procedure while tackling the stress of trying to get a straight answer about how much that care costs.
Andrea decided last year that she wanted to freeze her eggs. At 36, she wished to relieve some of the pressure of having kids before she was ready.
Andrea, who works at a major tech company, knew the process would be lengthy and expensive, but she figured the $20,000 fertility benefit provided by her company would cover most of the cost, leaving her on the hook for, at most, $4,000.(We're not using Andrea's last name or the name of her employer at her request, to protect her privacy. Her last name and employer are known to Business Insider.)Advertisement
In May, Andrea went in for an appointment at a Spring Fertility clinic in the Bay Area (she'd picked the clinic at the recommendation of a friend). She was prescribed medications routinely used as part of the egg-freezing process.
That's when the trouble started. She found that the cost of her prescriptions would use up nearly her entire benefit, leaving her with far larger bills than she expected."As a woman, I heard it can be taxing emotionally and physically, but I never realized there'd be this financially emotionally distressing component to it," Andrea said. "The financial part made it more stressful than I ever anticipated."
Unclear prices and surprise bills are common in the US
After getting the receipt, she contacted the pharmacy and representatives from Cigna's benefits team, as well as her employer. She also contacted Business Insider.
Here's what we managed to figure out.Andrea's receipt showed she was charged the list price, or more, for several of her medications, not the lower prices that insurers often negotiate.Advertisement
Cigna owns Freedom Fertility, having acquired the Newbury, Massachusetts-based specialty pharmacy as part of a 2018 deal.
A Cigna spokeswoman said the health insurer wasn't acting to benefit its own corporate interests over Andrea's, adding that Andrea didn't get a full picture of how her insurance would cover her prescriptions because the receipt she saw didn't factor in discounts insurers get from pharmacies. She also said Cigna negotiated lower prices for the drugs and would have used those lower prices to determine how much of Andrea's insurance benefit would be used up.
Paying the same pharmacy without insurance ended up being cheaperAndrea's doctors prescribed her five medications as part of the egg-freezing process. She was sent the prescriptions with the following prices on an accompanying receipt.Advertisement
The prices for Gonal-F and Cetrotide were in line with the cost at which they're sold to wholesalers, the drugmaker EMD Serono said; the prices for Menopur and Novarel were also in line with wholesale prices, a spokesperson for Ferring Pharmaceuticals said; and the price for Leuprolide was higher than its $712 list price, a Sandoz representative said.
The amount patients pay for each drug is determined by pharmacies and health insurers — and not directly by drugmakers. Patients going through fertility treatment often run into trouble affording their medications, partly because of complications with their insurance, the website Clear Health Costs has reported.Michael Ciman, the senior director of operations at Freedom Fertility Pharmacy, told Business Insider that the prices on Andrea's receipt reflected the prices that the pharmacy bills all insurers before any discounts. Typically, pharmacies then negotiate a discount off that price with the insurer, he said.Advertisement
Patients can get a discount off the list price of the fertility medications when paying in cash, Ciman added. Because a large percentage of Americans aren't insured for
High drug prices are common in fertility treatmentPeter Klatsky, the founder of Spring Fertility, Andrea's clinic, said he often sees patients hit with higher prescription costs, especially if their insurance doesn't specialize in fertility coverage.Advertisement
Generally, health-insurance plans aren't required to cover fertility treatment, though coverage is mandated by more than a dozen states. Sometimes, fertility coverage is provided separately, and it's a big business for companies like Progyny, Carrot, and Kindbody, as more companies look to cover fertility benefits.
Fertility treatments can cost tens of thousands of dollars. For in-vitro fertilization, the process can cost between $40,000 and $60,000 from start to finish, according to FertilityIQ, a website that provides information on fertility treatments. Egg-freezing itself can cost as much as $20,000 per cycle to complete, not including storage.Read more: There's a boom in VC funding for fertility startups. But female founders say they still have a hard time getting men to invest.Advertisement
Spring Fertility said it has a team that helps patients figure out billing and insurance issues, such as whether and how their prescription costs will be covered. If a patient's prescriptions will take up a fair amount of the overall benefit, Spring's team would advise that patients pay for their drugs in cash, rather than use their fertility benefit.
Klatsky said Spring Fertility has negotiated with pharmacies to provide a lower cash price. The total cost can be anywhere from $4,000 to $6,000, depending on which medications are needed.That's roughly how much Andrea ended up paying. After protesting the amount she was charged, she worked out a deal with Freedom Fertility to pay $4,687 in cash, and not use her insurance.Advertisement
After lengthy conversations with her Cigna representative, Andrea said, she was told the insurer would cover 70% of the amount she paid out of pocket. The insurer had previously told her she'd have to pay the full amount, she said.
For her second round of medications, Andrea opted to use a different pharmacy recommended by her clinic, where the total cost of the medications came to $4,100 in cash. She has since completed both rounds of egg retrieval.Andrea was reimbursed a portion of the costs for both rounds of medication, spending about $2,600 out of pocket.Advertisement
In total, including facility fees related to the egg-retrieval process, she ultimately spent about $8,500 herself. That doesn't include annual storage fees.Should Andrea go through the IVF process with her stored eggs, it would be another cost she'd be expected to pay herself. But for now, the stress of getting to the bottom of her prescription costs is behind her.Advertisement
"I'm relieved to have it in the past," Andrea said.
- Read more:
- The coronavirus pandemic is upending the way patients get their prescriptions. Meet the 8 pharmacy startups competing to take a bite out of the $335 billion market for prescription drugs.
- VillageMD just raised $1 billion and Oak Street is going public. Meet the 8 primary-care companies building a new future for medicine during the coronavirus pandemic.
- Walmart's ambitions are becoming clearer as it pushes into the $3.6 trillion US healthcare industry. Its plans make the retailer a 'sleeping giant to watch.'
- Telemedicine startups have raised hundreds of millions as the coronavirus puts them to the test. Meet the 12 startups forging a new path for healthcare.
- Bio-secure bubbles – Here's how IPL players will be staying safe during the pandemic
- INTERVIEW: Chennai-based CAMS’ 30-year journey to an IPO
- Amazon pumps in money into MORE to take on the heavyweights Reliance Retail and DMart
- 30 COVID vaccine candidates being developed: Health Ministry
- INTERVIEW: Paytm trains its guns on Google while the payments app is back in Play Store