Radicava copays with private insurance

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KarenNWendyn

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Maybe this should be a new thread, but does anyone on this forum know what kind of co-pays occur for Radicava with private insurance (non-Medicare)?
My experience when I was working as a rheumatologist, prescribing biological infusion drugs for patients with rheumatoid arthritis, was that if they had Medicare plus a secondary insurance, they had virtually no out of pocket cost. However, if they had private insurance such as Blue Cross, but no Medicare, the out of pocket costs were exorbitant. If they had Medicare without a supplement, they were screwed. I'm assuming Radicava would be similar in that it is an IV therapy which can be billed under Medicare part B.
Interestingly, the opposite is true for expensive oral or injection drugs. I.e. They are often unaffordable for Medicare patients because they hit the donut hole quickly trying to buy these drugs through Part D, and the out of pocket costs in the donut hole are quite high (at least $3000 a year, as of a couple years ago).
 
I made a new thread because I do think it deserves it. I am guessing you are right ( I don't know) and suspect the company thinks so too which is why they set up copay assistance.

If anyone has got this far with private insurance would be curious to know.
 
Depends on your plan's carveout of IV specialty drugs administered outpatient -- 4th tier part D (meaning $$$$ depending on plan design) vs. in medical benefit (Part B) bc administered in doc's office/infusion center/home.

Unless you know going in that you don't have to be worried, explore all the reimbursement options, e.g. picking it up yourself and bringing it to the infusion center vs. its being supplied there, administering at home vs. doc's office, administration by home health agency, etc. Quite often your cost share can differ across options.

Also look at separate pharmacy deductible/home health cap per year (visits and dollars) if need be. Every plan has some kind of OOP cap but what it applies to can differ.

You can also look on the plan Web site for how RA and MS infusions are handled but when a plan carves out "specialty pharmacy" and "disease management," ALS doesn't have to be treated the same as MS; depends on what the PBM or DM vendor is contracted for.

I realize this is a lot of "it depends," but it does, more than people think. When you get an answer from someone, if it is not explicit in your plan certificate, check it twice, document who said what when, etc.
 
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I think a lot depends on what your particular insurance plan looks like. I am still waiting on the pre-authorization to be completed with my insurance company (BCBS). I do know that my health plan has an out of pocket max of $2400 per individual. So it comforts me to know that even if my copayments end up being high it will max out at $2400 (less, considering as I've already spent money from regular visit copays since January) and then it will be free the rest of the year.
 
Kristina - Be sure that the out-of-pocket maximum ($2,400) applies to drug coverage. In my experience with Medicare Advantage plans, the out-of-pocket limit is only for medical--not drugs. (Maybe an infusion is medical) I've recently had Prolia (adminstered by injection for osteoprosis) and the copay doesn't count toward out-of-pocket expense.
 
Kristina1 - BCBS told us no prior authorization was required for them?
 
Eliz the different BCBS often have different policies with different rules Kristina may have BCBS of MA and you likely have a different company as you are in LA?
 
old dog- my drug coverage has a $1500 out of pocket max. My doctor isn't sure which way they will bill it- and it may be itemized (medical for the infusion center component, drug for the drug itself). It would actually be to my benefit if it goes under prescription drug coverage since that one's out of pocket is 1000 less.

eliz- I have BCBS out of NJ even though I live in MA. My husband's company contracts with BCBS of NJ for whatever reason. I'm not sure if the pre-auth was strictly required or if the neurologist felt it best to get pre-auth so there'd be no surprises later.
 
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