Drug insurance that covers Pegasys in US

[Doxy46]

Does anyone in US on Medicare have a drug plan that covers Pegasys or has a low copay? I need to change my drug plan this year.

[hunter5582]

I have a Medicare Part D plan that is managed by Cigna. It covers Pegasys, Besremi or Jakafi all for the same copay of $100/month, if it is approved. Note that every plan is different even when they are managed by the same company. You will need to check the formulary for each plan you have available.

[Doxy46 in reply to hunter5582]

Thanks Hunter. I'm on an AARP Part D plan via United Healthcare. They moved Hydroxyurea up to Tier3 last year. I used to have a copay of $18. It jumped to $120. I can buy it cheaper for cash at Walmart. I thought if I am going to change plans anyway, I might as well go with a plan that covers Pegasys, et al since after 13 years on hydroxyurea I suspect I will need to make a change in the next year or two.

[hunter5582 in reply to Doxy46]

An insurer charging charging $120 for a cheap medication like hydroxyurea is gross profiteering. Here is the retail cost.

goodrx.com/hydroxyurea oral capsule: 500 mg (60 ea): $25.00

What is happening is that United Healthcare is making an obscene profit on the sale of a very cheap medication, charging you more than the actual retail cost. This is called a clawback, where the insurer/pharmacy benefit manager pockets the money you pay beyond the real cost as a profit. The fact that they are permitted to charge this way should be illegal, but it is not. It is truly an abomination.

All the best finding a new, more ethical, insurance plan.

[Hilomom in reply to hunter5582]

We're fortunate that my employer provided insurance has a $0 co-pay for my husband's Hydroxy.

[Doxy46 in reply to hunter5582]

Thanks for your input Hunter. The prices they quoted is for 180 capsules every 3 months, but I agree it is quite high. This is a Walgreens only plan. When I told UHC that I was considering reporting them to Medicare, they said the price was set by Walgreens, not them.

[Mirror368 in reply to Doxy46]

Hi Doxy46,

Always look on Goodrx..com to find a coupon. It is a legitimate way to save money. My GP’s office even has flyers at their reception desk. I have not checked into it yet but just noticed that Amazon Prime offers amazing drug prices using your insurance.

I am fortunate to have a retiree drug plan. However, every year I go on the Medicare website, list my husband’s drugs and compare the current drug plan offerings. We have been changing his plan at times.

Good luck on your search, Eileen

[Doxy46 in reply to Mirror368]

Yes, GoodRX is great. That's how I found the cheaper price at Walmart.

[Dan73 in reply to Doxy46]

Are you getting generic hydroxyurea or name brand Hydrea? Thirty hydroxyurea caps cost me a copay of $2.49. My Part D plan requires me to pay 25% of the drug cost. Maybe your doctor is specifying the name brand. I have no idea how expensive that would be.

[Doxy46 in reply to Dan73]

Dan73, I'm on generic. Who is Part D insurer? That's a great price!

[Dan73 in reply to Doxy46]

Express Scripts from former employer. You might want to check out Amazon Pharmacy.

[Doxy46 in reply to Dan73]

Thanks. Since I wrote that post, I switched to a Cigna's highest level plan and my co-pay on the hydroxyurea is around $8 for 3 months through Express Scripts. However, I just found out my copay on a Prolea shot for osteporosis is over $900. That is crazy because my prior less expensive United Healthcare plan through AARP was 0 copay for Prolea. So once again, I will be shopping for a new drug plan at the end of the year. And I will have to wait until then to get the Prolea shot. Thank goodness this is not for a life threatening condition.

[Bikecrazy in reply to hunter5582]

Interesting, Hunter. I also have Medicare Part D with Cigna. They quoted a much higher charge for me for Besremi. Wondering what is different. What dosage are you currently on, if you don't mind sharing.

[hunter5582 in reply to Bikecrazy]

Besremi only comes in a prefilled 500mcg syringe in the USA. I actually take 150mcg and waste the remaining 350mcg.

What is different is the plan that you are on with Cigna. Cigna has many different plans with different formularies. I am on a retiree employer-sponsored plan that has a $100 cap for any monthly dose of an approved medication. There is also a $2,000 annual cap for out-of-pocket expenses for medication. While getting higher tier medications approved can be a challenge, affording the medication once approved is better on this plan than many others.

The good news is that there is an annual cap on out-of-pocket medication expenses being phased in for everyone on Medicare Part D plans. In 2025 the cap will be $2,000. In 2024 this amount will be $3,333. The formula for 2023 is different and significantly more costly. kff.org/medicare/issue-brie...

Suggest that you look to what the 2024 plan look like with your currently plan for 2024. If you will be considering a change during Open Season, you can then compare the Besremi cost across plans.

Here is a good starting point.

medicareinteractive.org/res....

This is the Medicare Find Plans tool. Note that using/understanding it is complicated.

medicare.gov/plan-compare/#...

[Bikecrazy in reply to hunter5582]

Thanks, I'll check into this before open enrollment.

[Meatloaf9]

Starting in early October you will be able to shop for a new drug plan on the Medicare website for a plan that starts on Jan 1 of next year. You can check the price of medications for the coming year while there. The prices I have found there have always been correct since the plans will have next year's covered drugs. So far it has been accurate, but when dealing with the government all bets are off. I have Wellcare Value Trust part D plan and this year I pay 15.00 for 180 caps of HU every 3 months. I won't know what the cost will be next year until I shop plans starting in early October. They list Pegasys as a covered drug but I don't think you would know until submitting for coverage. When I looked it up it was about 7,000 for a year of Pegasys and about 12,000 for a years worth of besremi. Best to you in finding a plan that works for you. Best always.

[saltmarsh]

Beginning in 2025, the Inflation Reduction Act caps out of pocket prescription costs at $2000/year for medicare receipents. Assuming I understand the commentary on it, that's a positive.