Insurance - Costs for Tafinlar and Mekinist

INSURANCE

This is information for those living in the US with medical insurance. Prices vary, but this might give you an idea.

According to GoodRx -

Tafinlar 75mg - $13,000/ month

Mekinist 2mg - $14,000/ month

Total - $27,000/ month

These are the typical starting doses.

As long as you have insurance and approval from them, you will not pay that full amount. It will depend on your deductible and out of pocket max. You will need to consult your insurance company and plan for this information. 

For example, your plan might have a $1600 deductible then you pay 20% of costs. Or, you could have a $5000 deductible and then pay nothing. And so on. There are so many scenarios. 

Then after you pay your deductible, you will have an "out of pocket max." That is the maximum that should be paid by you for that year. 

Your out of pocket max might be $8000, just as an example. This often includes medical and prescriptions. So it would include things like doctor appointments, CT scans, and prescriptions. 

Once you spend this much out of your pocket, insurance will pay the rest at 100%. 

INSURANCE EXAMPLE

So with these basic numbers, if you have a $1600 deductible and then you owe 20% of costs (insurance covers 80%), your cost for January 2023 would be: 

$1600 deductible owed

$5080 (20% of remaining balance of $25,400 for the two drugs) owed

A total of $6680 is owed by you in January for the two drugs in this scenario, because your deductible is starting over for the year. And nothing else has been charged or paid yet. 

Then in February, if you have an out of pocket max of $8000, you'd owe the remaining $1320. 

However, if you have CT scans and medical costs prior to February, this remaining $1320 may be due sooner. In other words, your out of pocket max may be met sooner. 

Once your out of pocket max is met, insurance pays in full for any medical or prescription costs for the remainder of the year. 

COPAY CARDS

As of writing this, Novartis offers copay cards, as well as a need based copay assistance. You will want to set these up ahead of time, before your deductible and out of pocket max are met. 

Copay cards are not need based. Anyone can apply and get them. The application process is easy. 

Call this number at Novartis for more information.

Novartis will pay up to $15,000 per year towards your out of pocket expenses. 

Sound too good to be true? It is. 

COPAY ACCUMULATORS

Unfortunately, most insurance companies use copay accumulators. This means they take this copay card assistance and apply it to their costs, not yours. So you do not benefit as a patient at all. Instead you still owe the exact same deductible, copay, and out of pocket max as always. With and without a copay card. Doesn't matter.

The only thing it will help with is delaying the payment of your deductible. The insurance company will apply the copay card to the amount they have to pay out to the drug company, Novartis. This in turn makes you owe less that month. But it won't change your deductible. So it only affects the amount you owe that month. 

And this will max out the card in the first use. It will use the whole $15,000 due to the prices of the two drugs. 

Then in February the same deductible and out of pocket max will apply when they process the next shipment of medication. This time their costs are not reduced since your copay card was already maxed out. 

So it will be time to pay the deductible. And eventually meet your out of pocket max.

With medications this expensive, that means you'll owe the same amount as you would have without a copay card, just delayed. I hope that makes sense.

WHY? 

The reason that the insurance companies use copay cards this way and allow them to not actually benefit patients is because they do not want patients to be compensated by a drug company to use a certain drug that costs more than others, and then they are stuck with the bill. This way of doing things is called using a "copay accumulator."

This practice of insurance companies using a copay accumulator is banned in a few states already. It simply doesn't help patients with costs and makes these drugs unattainable for some. So check your state to see if it's a thing there.

The flip side is, the copay cards themselves, in their own documentation, are meant to help patients with their out of pocket costs, not insurance companies. So it's conflicting - should it help the patient or insurance company. 

A WAY AROUND IT? 

There is a possible way to get copay assistance to benefit you.

I have not tried this, but we read that instead of using the copay card via the pharmacy, you can ask Novartis if they can reimburse your costs if you pay it in full without submitting a copay card to the pharmacy. This is often possible from what we understand and should benefit the patient instead of the insurance company.

You'd need to be able to pay it in full in cash though, I believe. And make sure it hits your insurance so you owe in full and are reimbursed in full, before anything else hits insurance such as a CT scan or medical visit. 

Talk to Novartis or your doctor about this. And make sure it'd work and is okay to do. This is just my understanding of things, as a patient. I do not know the ramifications or further detail. 

NEED BASED ASSISTANCE 

Again, we haven't tried this, but Novartis has at least one need based program where you can submit financial documents and if you qualify, they help you with your prescription costs. This may be of benefit to you as well.

These are life saving drugs and need to be attainable for anyone who needs them.

OTHER

And worst case, you can try the American Cancer Society. And maybe other charities that help with the costs of life saving medications such as these. 

NOTE

We are no experts with insurance, nor are we medical professionals. This is not advice, but purely just sharing things we read and basic things we understand. Please check this information out on your own. I am only a patient and am trying to navigate this just like you.