Puzzled by drug prices

It's really weird here with Orgovyx. It's $2,500 a month if you're uninsured. If you're insured by a private health insurer, you need to get a preauthorization for it. I was somehow able to get this--not sure what my doctor wrote to let me take Orgovyx instead of Lupron. Lupron is the standard drug most insurance companies will approve.

The weird part is that, if you have private insurance, the company that makes Orgovyx will pick up all of your copay except for $10. My copay would have been $100 but they pay $90 of it. If you're on government insurance, though (Medicare or Medicaid) they won't pick up the copay.

I know there must be big bucks in it, though, because my cancer center provides it to me directly instead of me going through a pharmacy like I do for other prescriptions, i.e. the cancer center is making money on it instead of the pharmacy.

That seems to be the case with some expensive cancer drugs. Here, I've always gotten my Firmagon and then Orgovyx (both about US$240/month) from my neighbourhood pharmacy, but my Erleada (about US$3,000/month) comes by courier from a specialised pharmacy; I think Janssen (Erleada's maker) has a special relationship with them. Also, it would be an expensive thing for a small neighbourhood pharmacy to keep on the shelves for the few people who'd use it.

My Canadian Cancer Centre doesn't sell anything, so there's no money in it for them regardless. They just try to figure out the best medications. I feel grateful that I don't have to second-guess their motivations.

(Prices quoted above are full retail, which I had to look up and convert to USD. I personally don't pay anything.)

The free market system in the States dictates the prices of medicines. The pharmaceutical companies here in the USA are totally for profit, and the more, the better. That is why there is/was a big trend for people from the States to mail-order their scripts from Canada.

When there is no generic equivalent, users are at the mercy of the pharmaceutical company. They must, of course, and rightfully so, reimburse themselves for the years of research, trials, etc. Yet they must also please their stockholders, the latter being the holy grail. I have attached a file for the 2023 profits for the top 10 pharmaceutical companies.

A lot of people make a lot of money over prescriptions. If you are uninsured then it's really tough to get the scripts you need because you can't afford them. I am so thankful I have Medicare and a Medicare advantage health plan that is provided to me by my pension system.

What is covered on your insurance plan is determined by the PBM (Pharmacy Benefits Manager) and your insurance company. Some PBMs will get a bigger discount by having Lupron on the formulary while others will have both on formulary. It all depends on what deal your PBM and Insurance company works out. Lupron is on most formulary's and most of the others need "prior approval" (some reason why Lupron will not work as well). This is a crazy American system that confuses everyone.

My health care provided wanted me to get zytiga from their specialty pharmacy but when my insurance provider got involved, the insurer redirected the prescription to my local cvs pharmacy. It doesn't have a price on it, and it comes at no cost.

We are retired professors and have original Medicare and a BCBS supplement provided through our long-time employer, Indiana University. When Dr. Kwon ordered Zytiga for my husband in January 2020, he sent the prescription to the Mayo Specialty Pharmacy in Rochester. It has been coming to our home since then directly from that pharmacy. It just depends on your insurance provider and the extent to which the evil PBMs are involved in that particular medication.

I receive my Orgovyx from the Mayo Specialty Pharmacy in Rochester. The retail price is $3000/mo. I'm on Medicare with a supplement plan. Beginning in January, my co-pay was $900/mo decreasing as I got into the donut hole and now free as I'm in the catastrophic range.

We pay more in the United States than any other country in the world for almost every drug. It’s because our Congress has made it very difficult for any company and Medicare to negotiate pricing. They finally passed a bill to allow Medicare to negotiate prices. This reduced the Price of 10 drugs down considerably and more will be done in the next few years. they also capped insulin at $35 a month when some companies were charging $400.

If you’re on Medicare, you pay a maximum of $8000. Once that is paid you pay no more for the year. That $8000 isn’t just based on what you pay it’s also is based on what your provider pays. In my case paying $2,300 for Darolutamide in January resulted in my paying zero dollars for drugs for the rest of the year. That’s because Darolutamide is $13,000 so the $8000 limit was reached immediately. My Orgovyx which cost $3000 was free for the rest of the year.

Forgot to mention that next year, the Medicare cap will be $2000. After that, you pay nothing.

That's good. Our system in Ontario is convoluted right now, but they're in the process of simplifying.

1. If you have private insurance (e.g. through work), they're the first payer.

2. Next, if you're < 25 years, 65+, on social assistance, getting homecare, or in the hospital, the Ontario Drug Benefit (ODB) will pay for your meds.

3. If you don't qualify for the ODB, then you can join the Trillium Drug Benefit, which will cap your prescription payments to 4% of your previous year's household income. Often, cancer drug makers will cover that 4% for you.

4. If your med is so new that it's not in the Ontario formulary yet, most drug makers have patient-access programmes that will cover the full cost.

Incredibly, I went through all 4 of these channels at different times for Erleada. My supply was never at risk, and I never had to pay a penny, but I could have done without the extra hassle. It will be great when universal pharmacare arrives (it's on the way).