Hello All -
I'm new here, so glad to join your forum. Just found out my monthly copay for Pegasys is $1000.00. Insurance caps specialty pharmacy drugs at yearly maximum of $10,000.00. But $10,000/yr is still more than I was expecting. The specialty pharmacy awarded me a $3200 grant to use so there is no copay for the first 3 months. Any suggestions regarding other ways to lower the copay? Organizations that provide financial support? Thanks,
It sounds like you must have a 25% copay plan with a very large annual cap. Perhaps you can shift insurance during the next open season. My copay for Pegasy or Besremi is $100/month with a $2,000/year cap. When you go on Medicare, you will find that effective 2025 there will be a $2,000 annual yearly cap. Hopefully more plans will follow suit.
Meanwhile, there may be assistance available. Suggest starting with the PAN Foundation. panfoundation.org/
Wishing you all the best.
Thanks for your input Hunter. My medical benefit out of pocket maximum is $7,900 (which I've paid 1200.00 so far) and out of network max is $10,000. In network deductible is $0 and out-of-network ded is $2500. My biotech/specialty injectable cost is $150 in-network and 50% after deductible for out-of-network. So I don't understand how they are determining a $1000.00 copay. The BCBS website states Pegasys isn't covered by my plan benefit, and shows "You will be responsible for the full amount of this medication". They don't cover Hydrea either - only the generic version. I'm going to call BCBS tomorrow to discuss with them further. PAN foundation gave a grant of 3200. But that was based on $12,000.00 yearly copays which I don't think is correct. I wish we didn't have to become experts at everything, but sometimes that is part of the journey. All the best to you too.
That does not seem to make any sense. Althoough it is used off-label for MPNs, Pegasys is a commonly covered medication since it is used for hepatitis. I have run into similar issues in the past with my pharmacy benefit. The pharmacy benefits managers do not always process claim correctly. Wrongful denials or misapplication of the plan rules occur far more often than people realize.
While the exact terms may vary by plan, your case should receive a medical services review, not an administrative review. It is common for the review process for non-formulary medications to be different. There can be similar issues with the off-label use of an expensive medication. The key in this situation is that the off label use of the medication is supported in the literature and/or is in common use. This is supported for Pegasys since it is in the NCCN guidleines for MPNs.
It is worth noting that hydroxyurea is also off-label for MPNs, though in common use. It is not surprising that the formulary would require that you use the generic version rather than the name brand Hydrea. It is the same drug in the same dose but the cost is different. Hydrea = 500 mg (30 ea): $47.00. Generic hydroxyurea = 500 mg (60 ea): $25.00. While the cost difference in chicken feed in drug costs, the insurance company will try to save every penny it can since it improves the profit margin.
I hope that you will find that your pharmacy benefit plan rules have been misapplied. It is important to note that the "patient navigator" you will be talking to does not work on your behalf. These employees work on behalf of the insurance company. Some may try to help but the bottom line is they work to ensure that costs are minimized. It is vey important to ask the right questions. One of the very important questions is to ask for a written copy of the "plan rules" that apply to your pharmacy plan. Get the patient navigator to define the terms used in your policy and the rules for off-label and non-formulary medications.
FYI - when my plan initially denied the Besremi, my doctor could not get it approved on appeal. I filed my own appeal, which turned into a Medicare Grievance due to their inability/unwillingness to provide me a copy of the plan rules on which they denied the Besremi. It took many hours of my time, but I won. I have not had a problem since.
Wishing you success.
How did your meeting with BCBS go?
I met with BCBS and a rep from the specialty pharmacy -they were very helpful. The copay is $1000.00 because Pegasys in a Tier 5 Specialty Drug, and my insurance plan requires me to pay 50% of the monthly cost (~$4400.00) up to $1000.00. Initially, I had been given incorrect information by the specialty pharmacy. The amount of copays I will be responsible for is capped by the yearly out of pocket maximum of my insurance - and that is very manageable. Because I typically have other healthcare expenses that go toward the out of pocket maximum, the reality is that my annual copay expenditure will be around $4000.00 to $5000.00, rather than what would have been either $10,000, or potentially $12,000, depending on the interpretation of what was communicated originally. I'm someone who would rather not know much about this, but it is really necessary in order to be a good consumer. Thanks for following up.
Glad to hear that you got this straightened out. You are absolutely correct that we need to be educated consumers of medical services. Insurance plans are complex and we do not always get accurate information about the plans. It takes persistence and assertiveness to access the benefits to which we are entitled. Congratulations on ensuring an appropriate outcome.
All the best moving forward.
Thanks for your kind guidance hunter.
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