Cost of Lupron shot - here's my bill/insurance

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compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7211
   Posted 2/4/2014 2:30 PM (GMT -6)   
I know from time-to-time we have mentioned the cost of a Lupron shot. I get the 4-month shot. My last one was in late October and I just got my bill. I think my insurance is pretty good, but let's compare. Note that my cost is after the usual insurance negotiated discount and then I pay a percentage, since my urologist is in-network
 
Office Visit: $92. My cost: $20
Urine sample: $14  My cost: $0.60
Lupron: $1024     My cost: $86.81
Administration of the drug: $75. My cost:$5.62
 
Hence, total bill: $1205 and my cost is $113.03
 
So, I'm curious how this compares.
My insurance is a group plan from work. I wonder what I'd be paying with Medicare (and supplement, probably). Less? More?
 
Mel

don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 2/4/2014 2:39 PM (GMT -6)   
Mel,

My cost, uninsured, for the same was $960. I now have insurance but have not had a shot yet.

Don

Break60
Veteran Member


Date Joined Jun 2013
Total Posts : 1851
   Posted 2/4/2014 4:39 PM (GMT -6)   
Mel:

From what I've read, your cost with medicare and a medicare supplement plan would be zero. I've had four surgeries in last 16 months including open three orthopedic surgeries and many MRIs and PT sessions and the only thing I have paid is the $147 part B annual deductible for medicare. Of course I pay monthly medicare and medicare supplement premiums. But I'm very happy with my coverages.

Bob

Casper319
Veteran Member


Date Joined Apr 2011
Total Posts : 771
   Posted 2/5/2014 1:18 AM (GMT -6)   
I get the 6 month eligard shot which comes up on the bill as around $1600....I pay $12 for the office visit.
Age:53 Diagnosed: April 2011, Age 50
Original PSA Level 92......Gleason: 9
Treatment: IMRT.... 2 Aug, 2011, 45 sessions
Lupron depot 30MG....3 years (started 13 July)
Now on Eligard every 6 months
PSA: May 2013...381, started Zytiga
Confirmed Bones Mets widespread...current treatment Zytiga/pred and HT
PSA down to 1.5 ...enrolled in Xofigo treatment...had first infusion 19 Sept

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 2/5/2014 7:48 AM (GMT -6)   
Mel, My office visit similar to yours was fully covered by Medicare Part B. Medicare usually covers all costs for meds administered in the docs office as well as all lab costs.

Carlos
PCa History and PSA Chart

Chart showing Recent PSA Trend

KeepRunning
New Member


Date Joined May 2018
Total Posts : 1
   Posted 5/30/2018 7:58 AM (GMT -6)   
Just got my bill from Aetna (Loyola Hospital Maywood, IL) for my 3 month Luprin Shot. Cost to give injection $412.00 Clinic Visit $118.00 Cost of the one shot of Luprin $10,213.34 for a total of $11,038.34
With discount from Aetna (-$5,323.41) net cost to me $5,714.93.
Need to buy stock in the drug company.

Saipan Paradise
Veteran Member


Date Joined Sep 2017
Total Posts : 664
   Posted 5/30/2018 8:25 AM (GMT -6)   
KeepRunning said...
Just got my bill from Aetna (Loyola Hospital Maywood, IL) for my 3 month Luprin Shot. Cost to give injection $412.00 Clinic Visit $118.00 Cost of the one shot of Luprin $10,213.34 for a total of $11,038.34
With discount from Aetna (-$5,323.41) net cost to me $5,714.93.
Need to buy stock in the drug company.

You gotta be shifting me! It would cost you less to travel to Saipan and pay out of pocket for a 3-month Eligard injection:
Round trip airfare from ORD (approx., economy, non refundable): $1,800
Two nights in the Hyatt: $360 (Mrs P & I will offer the guest room and spare you this cost)
Clinic visit: $100
3-month Eligard from CHCC outpatient pharmacy: $1,427
$100 per diem x 4 days: $400
Total: $4,087, or $3,727 if you bunk with us.

I’m paying $165 copay Eligard + $25 copay office visit, FepBlue BC/BS.
Age 60 at dx 7/2017 biopsy G8 (4+4), 5/13 cores
RARP 8/2017 (Patel), pT3a N0 M0, 30% tumor; EPE+, SV-
PSA 1/2016, 2.9; 4/2017, 7.2; 9/2017 (post-RARP), 0.13; 10/2017, <0.05, 1/9/2018, 0.09, 1/31/2018, 0.10, 2/9/2018, <0.05(!?), 2/23/2018, 0.08.
Eligard started 3/2/2018. SRT started 3/12/2018, 72Gy
Caution: I’m not an MD and don’t know what I’m talking about.

LifeCointosses
Regular Member


Date Joined Feb 2018
Total Posts : 47
   Posted 5/30/2018 8:49 AM (GMT -6)   
Having never heard of Lupron before I received a fast education, it is in a group of medications that is covered either under part B or part D for those on Medicare. Before I received my first shot I asked my Social Security Advantage plan for a quote. First thing they asked me was will my doctor provide the drug or will I pick it up or be provided by a pharmacy. The doctor buys on open market and determines the cost of the shot in office. For me it was far cheaper in office under part B. Cost of 6 month shot $2058, total office visit $2257. My cost $258. Lowest cost under part D drug benefit was $10,000.

Post Edited (LifeCointosses) : 5/30/2018 7:52:36 AM (GMT-6)


Naples
Regular Member


Date Joined Dec 2016
Total Posts : 69
   Posted 5/30/2018 8:53 AM (GMT -6)   
Gents,

The world of insurance is complex. You need to do your homework before selecting coverage for this treatment. Depending on your "out of pocket" portion of your policy, it may be wise to seek a policy that offers coverage of Lupron as a medical benefit versus pharmacy. Some of these carriers only offer the benefit when under a group policy (meaning an employer policy). I have an LLC that allows purchase of a group policy with only 2 employees, my wife and me. As long as you have some 1099 income you can do this. Here is my Lupron bill for the 3 month injection:

OFFICE OUTPATIENT VISIT 25 MINUTES - 99214 (CPT®) 323.00
LEUPROLIDE ACETATE SUSPNSION - J9217 (HCPCS) 2,601.00
CHEM HORM ANTI-NEOPL SB-Q/IM - 96402 (CPT®) 237.00
UHC Payments and Adjustments -83.69
UHC Payments and Adjustments -2,181.10
05/03/2018 CO-PAYMENT -40.00
Professional Services


My cost 856.21
DX 7/2016. 61 years of age. Radical Prostate Surgery 9/28/2016. G9 5+4. 3 nodes positive. T3b, Casodex & Lupron 2 years. Radiation, 39 completed 3/17/2017.
PSA 7/2016 4.5
PSA 10/2016 1.87
PSA 4/2017 0.0
PSA 7/2017 0.0
PSA 10/2017 0.0
PSA 2/2018 0.0
PSA 5/3/2018 0.0

NKinney
Veteran Member


Date Joined Oct 2013
Total Posts : 1159
   Posted 5/30/2018 8:58 AM (GMT -6)   
The differences in the charged amounts 4-years apart is staggering. I'd be interested in hearing what others are being charged (not what they are paying, which is going to depend on many other things) in the U.S. for these same services these days, so if you've recently (2018) had these services, what was the bill you saw? We could "average" the rates seen from across the country for a current value.

...............................2014...........2018...........delta
Office visit..................$92...........$118..........+28%
Urine sample..............$15.............n/r............. n/a
Lupron...................$1,024......$10,213........+997%
Admin of shot.............$75...........$412........+550%

Naples
Regular Member


Date Joined Dec 2016
Total Posts : 69
   Posted 5/30/2018 9:32 AM (GMT -6)   
Gents,

The world of insurance is complex. You need to do your homework before selecting coverage for this treatment. Depending on your "out of pocket" portion of your policy, it may be wise to seek a policy that offers coverage of Lupron as a medical benefit versus pharmacy. Some of these carriers only offer the benefit when under a group policy (meaning an employer policy). I have an LLC that allows purchase of a group policy with only 2 employees, my wife and me. As long as you have some 1099 income you can do this. Here is my Lupron bill for the 3 month injection:

OFFICE OUTPATIENT VISIT 25 MINUTES - 99214 (CPT®) 323.00
LEUPROLIDE ACETATE SUSPNSION - J9217 (HCPCS) 2,601.00
CHEM HORM ANTI-NEOPL SB-Q/IM - 96402 (CPT®) 237.00
UHC Payments and Adjustments -83.69
UHC Payments and Adjustments -2,181.10
05/03/2018 CO-PAYMENT -40.00
Professional Services


My cost 856.21
DX 7/2016. 61 years of age. Radical Prostate Surgery 9/28/2016. G9 5+4. 3 nodes positive. T3b, Casodex & Lupron 2 years. Radiation, 39 completed 3/17/2017.
PSA 7/2016 4.5
PSA 10/2016 1.87
PSA 4/2017 0.0
PSA 7/2017 0.0
PSA 10/2017 0.0
PSA 2/2018 0.0
PSA 5/3/2018 0.0

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2878
   Posted 5/30/2018 10:04 AM (GMT -6)   
Mel, if you had Medicare Part B and a supplement (say Medigap plans F or G), I'm reasonably sure you'd pay $0 for a shot administered in a doctor's office. Now whether the cost of the Medigap plans (low $200s/mo in So Cal), plus the Part D plan you'd have to buy would be worth it or not, is difficult to say. But I'd bet a good math prof could calculate it.

Hope you're doing well!
Age 57, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/18: PSA = 0.09

Bobby Mac
Veteran Member


Date Joined Mar 2016
Total Posts : 719
   Posted 5/30/2018 11:24 AM (GMT -6)   
3 month lupron injection U of Miami Sylvester - Medicare B

Payment Summary
Total Amount Charged:
$24029.00
Total Non-Covered Charges:
$0.00
Medicare Approved:
$24029.00
Medicare Paid You:
$0.00
Medicare Paid Provider:
$540.60
Total Amount You May be Billed:
$137.90 (paid by secondary insurance)

Bobby Mac
Age: 69 at PC dx, PSA 6.7 Biopsy: 2/16 13 of 14 Positive, - RALP 4/16 Path:EPE, 2 + margins, Gl 4+3=7, 50% of gland, Stage pT3a N1, nodes 2/10,+, 68 Ga PSMA 8/16 left node +, bed +, DECIPHER .85, Lupron 8/16 - 6/17, Firmagon 7/17, uPSA 6/16, 2.41, SRT completed 12/16, PSA 6/2016, 2.6, 7/16, 2.2, 8/16 .6, <0.1. since 10/16, 1/17 T=43 5/17 T=34, 6/17 T=25, 7/17 T=25, 9/17 T=48. T< 20 since 12/17

Saipan Paradise
Veteran Member


Date Joined Sep 2017
Total Posts : 664
   Posted 5/30/2018 11:55 AM (GMT -6)   
Bobby Mac said...
3 month lupron injection U of Miami Sylvester - Medicare B

Payment Summary
Total Amount Charged:
$24029.00
Total Non-Covered Charges:
$0.00
Medicare Approved:
$24029.00

Can anyone who’s worked in the healthcare industry defend sending UM Sylvester $24k in tax dollars for supplying one 3-month Lupron injection? Sounds like a sweet deal. I wanna piece of that.
Age 60 at dx 7/2017 biopsy G8 (4+4), 5/13 cores
RARP 8/2017 (Patel), pT3a N0 M0, 30% tumor; EPE+, SV-
PSA 1/2016, 2.9; 4/2017, 7.2; 9/2017 (post-RARP), 0.13; 10/2017, <0.05, 1/9/2018, 0.09, 1/31/2018, 0.10, 2/9/2018, <0.05(!?), 2/23/2018, 0.08.
Eligard started 3/2/2018. SRT started 3/12/2018, 72Gy
Caution: I’m not an MD and don’t know what I’m talking about.

Bobby Mac
Veteran Member


Date Joined Mar 2016
Total Posts : 719
   Posted 5/30/2018 12:12 PM (GMT -6)   
Medicare only paid approximately 2.3% of the $24,029 - so the real impact presumably would be felt by people with high co-pay insurance plans & those without insurance.

Bobby Mac
Age: 69 at PC dx, PSA 6.7 Biopsy: 2/16 13 of 14 Positive, - RALP 4/16 Path:EPE, 2 + margins, Gl 4+3=7, 50% of gland, Stage pT3a N1, nodes 2/10,+, 68 Ga PSMA 8/16 left node +, bed +, DECIPHER .85, Lupron 8/16 - 6/17, Firmagon 7/17, uPSA 6/16, 2.41, SRT completed 12/16, PSA 6/2016, 2.6, 7/16, 2.2, 8/16 .6, <0.1. since 10/16, 1/17 T=43 5/17 T=34, 6/17 T=25, 7/17 T=25, 9/17 T=48. T< 20 since 12/17

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3794
   Posted 5/30/2018 12:23 PM (GMT -6)   
There is no one answer.

For Medicare it depends on the plan you have. If you have traditional Medicare and Supplement F you would have no out of pocket cost. Supplement G you pay the $183 Plan B deductible. Other supplement plans will have other levels of out of pocket expenses. If you opt out of Medicare and into an Advantage plan you will have deductibles and co-pays based on the specific plan you choose that is offered in your area.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Progressing
Regular Member


Date Joined Aug 2017
Total Posts : 244
   Posted 5/30/2018 12:26 PM (GMT -6)   
Bobby!ac, yes, and it’s also how hospitals, doctors, and pharmacies drive up the medicare reimbursement — they can claim the difference between “cost” and “medicare reimbursement” as a loss, then push for medicare to raise the reimbursement to reduce their loss.
Also, if you have a medicare advantage plan, i think you have to pay the difference between “cost” and”medicare reimbursement.”
Age 76, Dx at 75
Psa 7/13=8 with BPH, 9/17=20.44
7/20/17, Biopsy, 5/12 cores PCa all right side, Gleason 4+3
Laparoscopic surgery MSKCC 10/31/17, left nerves spared, pathology T3aN0, G4+3, focal EPE, negative margins,
Continent but ED
12/14/17-psa 0.10; 1/25/18-0.11, 3/5/18 - 0.12, 3/30/18 - .12, 4/30/18 - .14, bone scan and MRI negative
First 3 of 6-month Lupron 4/30, SRT in July

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3794
   Posted 5/30/2018 2:33 PM (GMT -6)   
Actually not, Progressing. What the provider bills is just a number they choose. Every provider negotiates with each insurance company and third party payor for the agreed reimbursement amount. Medicare publishes their reimbursement amount publically and it is in no way connected to the billed amount. The billed amount means nothing.

All Medicare Advantage Plans are private insurance contracts and have a clear contractual schedule as to what costs are born by the insured and it has nothing to do with the difference between what is billed and reimbursed. Remember, Medicare Advantage claims are not submitted to Medicare as they have nothing to do with the reimbursements.

Medicare has an exacting schedule as to what it reimburses and is on their website. When they change these schedules it is done clearly in the public for those that want to know. They are in no way influenced by providers posting high bills that they know will not be reimbursed. And the difference between billed and reimbursed is not a "loss". It in no way figures into any accounting for financial reporting or taxes.

I suggest you pay no attention to the billed amount as it is basically meaningless.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

alephnull
Veteran Member


Date Joined Dec 2013
Total Posts : 845
   Posted 5/30/2018 2:56 PM (GMT -6)   
Eligard 3 month shot, insurance paid $1931, I paid $0
My PSA Curve
Previous PSA
Curve

Treatment Path
My Story

Bobby Mac
Veteran Member


Date Joined Mar 2016
Total Posts : 719
   Posted 5/30/2018 3:07 PM (GMT -6)   
I have straight Medicare Part B, but I also kept my employer insurance when I retired. Better than a supplemental plan as it includes prescription drugs and offers lower co-pays than any Part "D" Plan I have seen.
Age: 69 at PC dx, PSA 6.7 Biopsy: 2/16 13 of 14 Positive, - RALP 4/16 Path:EPE, 2 + margins, Gl 4+3=7, 50% of gland, Stage pT3a N1, nodes 2/10,+, 68 Ga PSMA 8/16 left node +, bed +, DECIPHER .85, Lupron 8/16 - 6/17, Firmagon 7/17, uPSA 6/16, 2.41, SRT completed 12/16, PSA 6/2016, 2.6, 7/16, 2.2, 8/16 .6, <0.1. since 10/16, 1/17 T=43 5/17 T=34, 6/17 T=25, 7/17 T=25, 9/17 T=48. T< 20 since 12/17

Union98
Regular Member


Date Joined Jan 2017
Total Posts : 56
   Posted 5/30/2018 3:53 PM (GMT -6)   
Our insurance is through my work and we have BCBS. In 2017, Lupron (only) was approx $8000 billed from the Oncologist to BCBS & BCBS paid approx $1700. 2018 the oncologist is now billing BCBS approx $2000 for a 3 month Lupron injection with BCBS paying the exact same amount to the office. Doesn't make a bit of sense!
Husband: Initial PSA 74.6 11/2016
12/2016 - MRI guided biopsy, CT lymph biopsy, NM bone. Path: Metasiatic prostatic adenocarcinoma,lymphadenopathy Gleason 4+3=7 (90% 4) 33mm of tumor 100% (3 of 3 cores) Perineural invasion 3 bone mets. Treatments: Lupron Casodex 2 months; Docetaxel 2/2/17 6 doses. Casodex 8/17; switched to Zytiga 12/17 bone mets greatly diminished. PSA .06 4/18

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 697
   Posted 5/30/2018 6:17 PM (GMT -6)   
It would make sense, for tax purposes, to charge $,2,000, or any amount, knowing insurance was only going to pay x number of dollars, and then take the balance as a write off.

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3794
   Posted 5/30/2018 6:20 PM (GMT -6)   
Mr Bill, that is simply not the case. Income you didn’t receive does not become a tax deductible expense.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Redwing57
Veteran Member


Date Joined Apr 2013
Total Posts : 2449
   Posted 5/30/2018 7:48 PM (GMT -6)   
It took some detective work, and I don't have a clear answer. The last statement I can find for a 4 month Lupron shot was in July 2015, and it says $3024 for the shot. At the same appointment, I got a Prolia shot (once/6 months denosumab), stated as $3180. The statement included several office charges as well. Insurance discounted the $6710 total by $2339 but no details. So, maybe split the reduction across the two larger charges, and let's say the Lupron shot cost about $2000 plus or minus.
55@Dx on 4/16/13. PSA 5.2, G9(5+4), cT3a by MRI.
IGRT - 44 sessions (79.2 Gy, 50.4 Gy pelvic)
ADT2 - Lupron+Casodex (3 yrs)

PSA <0.1 : 8/13 - 5/16; steady at 0.7+/- 0.1 since 3/17

My Story

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3794
   Posted 5/30/2018 8:25 PM (GMT -6)   
My Lipton/eligard shots were all reimbursed at about $1,300- each for six month shots. That was some five years ago and probably are a bit more now. I don’t remember what they were billed, but that number is meaningless so no need to remember it.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta
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