One of These Things is Not Like the Others: A Health Insurance Tale

~ snakesinthegrass2014
The smaller American brand of Estrogel, dwarfed by its European cousins

Blogger’s Note #1: This post is partly about female hormone health and includes brief mentions of female anatomy. Reader discretion is advised.

Blogger’s Note #2: I am once again joined by the adult in the room, a/k/a Gorgeous, and we are writing this post together. Her comments are preceded by a “(G)” while your humble blogger’s are noted as”(M).”

And now, on with the show…

(M): Every couple has its division of labor. In our home, I am the one who handles all things insurance, be it auto, homeowners, or healthcare. Although I consult with my lovely wife if I decide to make any changes, I am both the primary decision maker and the “fixer” when things go kaput. Whether I like it or not (I don’t), navigating the healthcare landscape is in my wheelhouse and not Gorgeous’.

We were inspired, perhaps the better word is emboldened, to write this post out of frustration with how drug manufacturers and health insurance companies take advantage of consumers. To international readers, particularly those from countries with national health insurance coverage, I once again virtually scream “I KNOW!!!” in acknowledgement of your open mouths and wide eyes.

Gorgeous uses an estrogen med called “Estrogel.” It has been on the market since 2004 and is still within its “patent exclusivity period.” As a result, with no generic alternative available, its cost to patients is quite high. The current co-pay for a 50 gram (1.75 oz) bottle under our coverage plan is $90 (for those with no insurance coverage, we learned from a recent trip to Costco that the cost is upwards of $190). One pump of the gel is applied to the inner arm, thigh, or abdomen twice a day, and it is assumed that one bottle officially lasts approximately 30 days if used daily.

When we first got married over ten years ago now, Gorgeous was over the moon in being covered under my work-sponsored health insurance plan. This was after years of having absolutely no insurance at all. While I am cautiously certain that my smooth and suave personality, coupled with my devastatingly good looks, were the sole reasons that she married me, there have also been lingering thoughts that it might have also been about the health insurance benefit. I’m told it’s best to let that remain all part of the larger romance mystique.

What I recall from one of our first visits to the pharmacy together after tying the knot, was how pleased she was that a (note: 80 gram) tube of Estrogel was approximately $60 back in 2012. Since that time, the cost of it has grown and its size has shrunk for American consumers. The drug maker isn’t even bothering to try and fool patients such as the way the consumer products industry does in the current “shrinkflation” phenomenon.

Source: Chicago Sun Times

(G): As Martin mentioned, I had no health insurance prior to our marriage. I lived on a Michigan farm raising goats and cows, and my ex paid out-of-pocket for some of my health needs. The rest was taken care of through limited Medicaid coverage from the county where I was living. My gynecologist was so wonderful back then that for a long time he agreed to barter office visits in exchange my homemade goat cheese and wheels of cheddar! He was such a kind man.

I started on estrogen replacement therapy at age 39 after a hysterectomy. I began with taking monthly estrogen shots, but found that their effectiveness started to seriously decrease by day 25 or so. I briefly switched to the patches but was frustrated by how they didn’t stick to my skin correctly. Finally at age 41, I started using Estrogel and have been using that ever since. For me it was critical in controlling hot flashes and night sweats, helping to stabilize my mood, keeping my skin healthy, and maintaining vaginal moisture. Circa 2010-2012, prior to our marriage, I recall paying approximately $110-120 for an 80 gram tube.

After Martin retired in 2014 and we moved to Florida, his new doctor offered that some of his prescriptions could be obtained less expensively if purchased from Canadian pharmacies. So that introduced us to a whole new way of obtaining some medications.

By this time, my $60 tube of 80 gram Estrogel was now $70 at our local pharmacy and seemingly heading higher by the month. When I compared its cost with the online Canadian pharmacies, I saw savings of approximately 60 to 70%. I discussed it with my then-gynecologist and she agreed to write me a prescription to snail-mail to Canada. Since that time, this is how I’ve been getting my prescription for Estrogel. It’s sometimes a little cumbersome with renewals, but I’ve still always managed to get the orders filled and eventually shipped to me (most of the online Canadian pharmacies require the actual hard copy prescription in order to fill it). I am currently paying $23 American for that 80 gram bottle; the product is made in Europe and shipped from the UK.

(M): Still with us? This is the part where things begin to get interesting. I don’t have to actually say that, but since Gorgeous has been doing most of the talking I thought you might have missed me.

Back to you, darling…

(G): It wasn’t until my recent breast cancer surgery that I had any problems in getting my annual prescription. However, my new gynecologist (the previous one had retired) refused to write a new one, pointing to the risk of Estradiol usage and cancer in post-menopausal women. I have discussed this very risk with all of my gynecologists every year since my hysterectomy, and I always arrived at the same place: that the benefits of estrogen replacement outweighed the risks. In being vigilant with my yearly mammograms, I was comfortable with that decision.

In what Martin referred to as a “Hail Mary pass,” I then asked my regular physician for a prescription. She unfortunately deferred back to my gynecologist. When I again queried the gynecologist, she said she would only fill it after consultation with my surgeon. It took several phone calls to both offices for that consultation to finally happen.

My surgeon weighed in with allowing me to continue to use Estrogel. It’s her feeling that since all of my breast tissue has been removed, plus the fact that my breast cancer was fortunately only stage zero, the risk of it reoccurring is low.

At this point, it’s probably best to address the elephant in the room: did I get breast cancer because of estrogen replacement usage? Honestly, I’ll never know. Cancer runs in my family and it very well may have been a reality for me. I remain grateful for the benefits of the medication, and I feel comfortable with my decision to have taken it and to continue taking it. It’s obviously a very personal decision with no one-size-fits-all answer for everyone.

My gynecologist ultimately accepted the surgeon’s decision and presented me with a new prescription for Estrogel.

(M): But in an administrative bungling, however, the office staff wrote the prescription for less than the usual quantity. Gorgeous therefore wouldn’t have enough to get through the year. Fortuitously, in addition to providing her with a paper prescription, they also bungled by electronically transmitted the very same prescription to our local pharmacy. So she now had two prescriptions.

Source: Walmart

Gorgeous paid no attention to our local pharmacy’s notification and dutifully mailed in her paper prescription to Canada as usual, thinking she would just ask for more when the time time came. I, though, sensing an opportunity, drove to the pharmacy and picked up her waiting prescription. I returned home a felon in the eyes of my suspicious bride.

Three weeks later her Canadian order arrived in a shipment from England. While the products are exactly the same — Estrogel/Oestrogel 0.06% transdermal estradiol gel — the size and costs are starkly different, as shown in the photograph at the top of this post.

  • The Canadian pharmacy order resulted in an 80 gram bottle/tube costing $23.00 (American) each.
  • The American pharmacy order, purchased with our health insurance co-pay, resulted in a 50 gram bottle costing $90.00. She has four renewals till February, which should easily coincide with her next yearly appointment at the gynecologist, where she can make doubly sure they write for the correct amount next time around.

Since the felony opportunity was instigated by yours truly, Gorgeous is looking the other way because she ultimately has what she needs (not to mention that I’ve duly offered to keep paying for that high co-pay at our local pharmacy). Can anyone spell co-conspirator?!!

My personal ethics aside, the real tragedy here is how the American health system, along with our lawmakers, continue to make it difficult for patients to obtain prescriptions at a reasonable cost. We are fortunate that we can absorb the amount being charged, along with being able to jump through all the ridiculous international hoops in order to get the needed medication. It’s a tragedy for those who don’t have the same resources yet still need such medication.

Until next time…

45 thoughts on “One of These Things is Not Like the Others: A Health Insurance Tale”

  1. I went through a similar situation when my cat was diabetic and required Lantus insulin. Yikes! My choices were to cash in my 401(k) or watch my cat die. Fortunately, there is a website dedicated to diabetic cats. Lots of info about the disease and tips on managing it including where to buy insulin, how to buy it and what to ask for. Part of the snag is that a cat uses so little a bottle “goes bad (?)” before you can use a quarter of it. Anyhow this has nothing to do with people stuff but it does reflect on the ridiculous prices we pay for drugs. My neighbor lived in Palm Springs, CA and said everyone there goes across the border for drugs (the legal kind, well, maybe the others too), dental work and some nips and tucks. She said the docs are qualified, the pharmacies clean and large and everything is legit (except that I don’t think you are allowed to get drugs like that). Food for thought.

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    1. I had a hair stylist once who got all of her elective medical procedures done in Mexico because of the cost and the quality. She was fully insured here but only used it when necessary such as doctor exams and when she didn’t feel well. Everything else was done in Mexico, where she had extended family. The leaps some of us have to make! You’re a good cat mommy and caretaker, Kate.

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  2. I have a hard time believing that anyone still thinks the U.S. “has the best healthcare system in the world.” It seems to be a delusion they hold until they actually need to use our healthcare system. Those drug prices are nuts but the pharmaceutical companies will keep charging whatever they can as long as we pay (and, of course, we have to keep paying). I’m glad you have the option to get the medication from a Canadian source. Our proximity to Mexico would make that an option for me and my husband. Fortunately, hubby doesn’t take any medications and my two are relatively cheap. If that changes in the future, I’ll be looking for sources in other countries too.

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    1. We have to devise so many different ways to figure it all out — like a Rube Goldberg matrix — and it shouldn’t be necessary to do any of it. Kudos to both of you for being able to avoid this. Keep it up, Janis! 👏

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  4. I’m peering down into my canyon of discontent regarding U.S. Healthcare, especially in our new home state. No, I won’t go there…. I’m happy to hear you two have worked this out. Also enjoyed your double-teaming another blog post.

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  5. Hmm, let’s see, is this an example of American exceptionalism? The power and glory of unbridled capitalism? Ensuring that Americans avoid the horror of experiencing that terrible evil, ‘socialism’?! Speaking from the other side of the northern border, sometimes popular drugs temporarily become rationed here in certain parts of the country because so many Americans have been buying them up! Our drugs are more affordable, I think, because of public policy and higher taxes to support those policies.

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    1. Didn’t know this, but then it makes sense…I feel bad that as everyday Americans (read: not one in power), such a makeshift, desperate – albeit tenuous – ‘solution’ makes this sort of impact upon you, our neighbors…it’s just nuts, ya know?

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      1. Exactly. And that’s an example of what Americans have been scared off of as being the dreaded ‘socialism’. God forbid that the well-being of citizens would take precedence over corporate profits! Call me cynical. 😊

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  6. It’s just bizarre, as Marty points out so well, that the richest country in the world doesn’t see fit to regulate the amount of profits the drug industry feels it deserves so that citizens have reasonable access. Interestingly, the oil industry is well subsidized, how about the pharmaceutical industry?! 😏

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  9. Unfortunately, your ‘story’ is one most of us in this country have to tell but with differing details. It’s hard enough having to navigate the maze of healthcare/cost of drugs/etc as one with few medical needs. I can’t even imagine for those like yourself who have gone through bouts of cancer & cancer related health problems.
    Stay strong, Gorgeous.

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  10. I am sorry that you and Gorgeous are having to deal with this. But I am glad that Gorgeous has her needed medicine for now, and there is a plan going forward for next year. But you are so right! These hoops are ridiculous, and people who don’t have the resources or the knowledge would not be as successful as you in figuring out the way around the system to get what they need. I sure don’t know what the answer is, but I suspect the problem lies in the pockets of our politicians.

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    1. You hit the nail on the head, Betty: that we’re able to maneuver around for what we need is great. But the larger problem — the tragic one — is that so many cannot; and they end up going without. It’s a deep tragedy and certainly the biggest “doughnut hole” in our healthcare system.

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  11. Marty, if only you had called, I could have had my own paragraphs. My husband gets one of his asthma meds from Canada. Instead of paying $300+, he pays $160. He does, however, have the same challenge getting a ‘paper’ prescription once a year that I fax on my phone to CN. On my side of the medical fence, I ‘have’ to use two eye drops that come in bottles with 0.271 us fluid ounces in them. I pay out of pocket $90 and $135 for the privilege of maintaining my eyesight. The first one of those that I get in a year costs me $325. One has been on the market since 2001 and the other since 2013. Our healthcare system is an embarrassment along with the fact that it drains our wallets affecting the quality of our medical and financial lives. I’ll stop there or I’ll enter into a few political comments, and politics is definitely not a topic I enjoy talking about. 🙂 Now, we should all take a few minutes to meditate because our current healthcare status tends to stir things up. Good post but sorry it was necessary.

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    1. Good lord for both of you, Judy. I’m glad there is at least an option of saving money, but the fact that we have to jump through such hoops for a country that allegedly leads the world in medicine and healthcare is beyond ridiculous. What I’ve left out of the post is that I no longer have to use the Canadian option because Mark Cuban’s “Cost Plus” miraculously has what I need. But he doesn’t have everything — his offerings are comparatively minor. It’s a start, though. Thanks for sharing. 😔

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  12. Bloody hell Marty, your system is surely broken. We feel that ours over here in the UK is, but by comparison, it’s only a little bit… if getting bigger under the control of our current government.

    In a rough few weeks, the story of your felonious behaviour put a broad smile on my face. And I’d have done the same as you to make sure there was sufficient stock in hand, principles sometimes have to be side-stepped.

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    1. Thanks for the statutory solidarity, Debs. You won’t be able to bail me out when the sheriff comes to arrest me, but I’m grateful for the support! 😉

      I try to follow some of the issues regarding the NHS on social media (Twitter mostly), and I know it’s certainly not a perfect system. I’m aware of how common it is over there to “go private” for certain procedures. But in the main, I’m still jealous of what appears to be a very well-built system to cover all citizens. Glad I could offer a smile for you.

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  13. What a story, but one that does ring true. Our healthcare system is a joke, which baffles and frustrates everyone. I do wonder about the estrogen replacement usage and breast cancer. Is it corollated or just a coincidence? Sometimes, when I’m feeling cynical, I think that insurance companies have reasonable rates on dubious meds, knowing that eventually they’ll make more money on the surgeries, procedures, and drugs that’ll be necessary later to cure you… after taking the dubious meds. But that can’t be true, can it?

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    1. Ah, proof positive that our healthcare system has made all of us paranoid, Ally! I sure hope that’s not true, but since so many medical centers are now corporate owned, there is reason to be suspicious. Apparently the correlation between estrogen replacement and cancer is there, yes. But they are also quick to add a multitude of caveats of cost benefits to make one’s head swim. 🤦‍♂️

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  15. “…I always arrived at the same place: that the benefits of estrogen replacement outweighed the risks.”
    Yes, 100%. It is an decision to be made by every woman individually based on their unique situation and background and based on informed consent.
    Quality of life can never be overestimated. Love this post!

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  16. As I write this, I am renewing my company’s health insurance plans. It is absolutely insane the premiums we, and our employees, pay. Then there are the high deductibles, co-pays, and the crazy prescriptions prices.
    On top of it all, there is the nightmare of dealing with insurance companies… I avoid going to the doctors, just not to deal with them.
    Best of luck to you and Gorgeous!!

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    1. Ah, then you view all of this from a very high-level perspective then, Ana. It’s really insane what we deal with in this country. I tried explaining the difference between co-payments and co-insurance once to a friend from the UK. You can imagine how that went. 🙄

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  17. I feel your pain – well not your pain, but my own pain in a related matter. Oh wait, I think there’s a word for that. Empathy? Frustration? Probably a mix of the two. Anyway, here in the Third World, you can use use state healthcare (which is a euphemism for dying in an unpleasant manner), or private healthcare. I spend approximately a tenth of my salary as a co-payment on insulin. When did life become a subscription service?

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  18. Good for you and Gorgeous that you chose to double dip without consulting with Gorgeous!

    I have double dipped on controlled prescription medication which my double dipping felt like a hoarding disorder. But good thing I did! I never told my doctor about my double dipping. But my doctor decided that I no longer needed the controlled prescription medication after my long 12 days in a ICU hospitalization this past January when those doctors diagnosed me with Congestive Heart Failure and now I’m on a whole different group of prescription medications!

    I was glad that I could count on myself to take care of my severe depression and extreme anxiety disabilities. It wasn’t a matter of costs as it is not at all expensive, but it is a matter of caring for my health pain and suffering. Our United States medical system is very broken and I don’t know when it actually broke. I’m with you on approving of double dipping. You may have felt like a felon and I felt like a prescription hoarder. This is what our medical state of affairs has come to.

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