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
Mel,
My cost, uninsured, for the same was $960. I now have insurance but have not had a shot yet.
Don
My cost, uninsured, for the same was $960. I now have insurance but have not had a shot yet.
Don
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
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
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
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
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
Carlos
PCa History and PSA Chart
Chart showing Recent PSA Trend
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.
With discount from Aetna (-$5,323.41) net cost to me $5,714.93.
Need to buy stock in the drug company.
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.
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.
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)
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
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
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%
...............................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%
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
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
Eligard 3 month shot, insurance paid $1931, I paid $0
My PSA Curve
Previous PSA
Curve
Treatment Path
My Story
My PSA Curve
Previous PSA
Curve
Treatment Path
My Story
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
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