Pegasus interferon covered by Insurance

[Auggie17]

I have been on Hydroxyurea for 20 months and am really feeling fatigued and ache all over. I am considering asking my MPN Specialist to put me on Pegasus. My concern is the cost. I live in Alabama and have Humana prescription insurance and am on Medicare. Does anyone know if it is covered by insurance yet?

[hunter5582]

There is variance by plan but my Medicare plan (managed by Cigna) covered Pegasys with no problem. This med has been around for a while and is most likely on the formulary. It is a good thing that it was covered. I could not tolerate HU and it was not effective for me. PEG as more effective and easier to tolerate. My quality of life improved due to PEG.

Wishing you success if you decide to pursue this.

[Auggie17 in reply to hunter5582]

Thank you Hunter and EPguy. My MPN specialist in April said it has a cost of 90,000$ per year and probably wouldn’t be covered. My hematologist said the side effects are way worse than hydroxyurea. I think they are both talking about 2 different Interferons. I am frustrated but will get to the bottom of it with my next visit.

[hunter5582 in reply to Auggie17]

That cost figure is not accurate. Approx cost is $50, 400/year. It is almost certainly on the formulary for its FDA approved use treating hepatitis. insurance will cover off-label use provided there is evidence to support it which there certainly is. Pegasys

Approximate Retail Price

from goodrx.com/pegasys

subcutaneous solution:

180 mcg/mL (1 vial, 1 mL): $1,052.00

subcutaneous solution:

180 mcg/0.5 mL (1 kit, 4 syringes): $4,177.00

It is also not true the the side effects of Pegasys are worse than hydroxyurea. They are different and vary widely by individual. I found HU to be ineffective and was not able to tolerate it. I experienced toxicity even at very low doses. PEG (and then Besremi) were much more effective for treating the erythrocytosis and thrombocytosis, and much easier to tolerate. I have only experienced very mild side effects. I wish I had not waited as long as I did to start the IFNs.

There is often a preference for HU over PEG in formularies due to the cost difference. The cost of HU went down. At 500mg/day it would cost $150/year. It would be no surprise if insurance companies preferred it. Do note that it will likely take extra work from the doc to get PEG approved.

Hydroxyurea

Approximate Retail Price

from goodrx.com/hydroxyurea

oral capsule:

500 mg (60 ea): $25.00

Go to your next appointment prepared with the facts. You can call your insurance provider and get the authorization process clarified in advance. It is important to know the plan rules for your plan.

PEG and HU are both acknowledged as first-line treatment options. We each respond differently to these meds. It should always be up to the patent to decide which is preferable. This is your choice to make.

If you have not already consulted with a MPN Specialist, suggest that you do so. MPNs are rare disorders. Many hematologists have little experience with them. Docs who deal with MPNs on a regulars basis are more up-to-date and know how to access treatment options. Here are two lists.

mpnforum.com/list-hem./

pvreporter.com/mpn-speciali...

All the best moving forward.

[Auggie17 in reply to hunter5582]

Thank you! This is very helpful. My MPN Specialist is Dr. Verstovsek at MD Anderson. I am thinking he was referring to Besremi maybe? He just said Interferon when he offered it.

[hunter5582 in reply to Auggie17]

Dr. Verstovsec is a well regarded MPN Specialist. Perhaps there was some confusion on the cost. Besremi comes in closer to $170,000 - $180,000/year.

Regardless of the cost of the medication, that is not typically what you pay - depending on your plan. There was no difference in my out-of-pocket between PEG and BES despite the different cost of the two meds. I pay $100/month until I reach my annual $2000 cap. Then it is 100% after that.

Note that while PEG was easy to get authorized, Besremi was a challenge. I did it back in January when BES had just been approved. I had to put a lot of work into investigating the plan rules them filing my own appeal. It was absolutely worth it. The IFNs have been more effective and much easier to tolerate.

Hope you arrange the treatment plan of your preference ASAP.

[Auggie17 in reply to hunter5582]

Thanks Hunter! Stay well!

[EPguy]

In your favor for requesting PEG, you can honestly say you're intolerant of HU. That should help make your case for an alternate treatment.

[Island-Lady]

I was on HU for 2 1/2 years and just switched to Pegasys Interferon. I have HMS AAA insurance. I was initially told who it would be $490 per month but I called my insurance and I called the specialty pharmacy and when build a different way my cost is zero. It is worth it to be proactive and research this for yourself. It required me saying that $490 was a lot for them to look up a different way to bill it. One of the differences on my insurance is that if it is mailed to my doctor and they inject it it is $490 but if it is mailed to me and I inject it it is free. I am so happy to be off HU and wish I had done it six months sooner. I wish you the very very best!

[Island-Lady in reply to Island-Lady]

So sorry I didn’t proofread that first😊hmsa. It was also supposed to say when billed a different way. Oops😊

[PhysAssist in reply to Island-Lady]

FYI, you can go back and edit your own posts later on- I have to do it a lot, so I know it works.PA

[Auggie17 in reply to Island-Lady]

Thank you so much! I appreciate the information very much.