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Regarding whether Kevzara would be covered by insurance if it was injected at a hospital, I can speak to that a little based on my experience with Actemra. I have a Medicare Advantage plan. When I was discussing Actemra last year with my doctor, he said that it is available through infusions or injections. My understanding is that the infusions would be covered by Medicare Part B, and the injections (which are done by the patient at home) would be covered by Medicare Part D. For me the Actemra either by infusion or injection had to be pre-approved by the insurance company. They approved weekly injections for me. I think in most cases the copays are higher for drugs covered by Medicare Part D than the ones covered by Part B. Last year the maximum out of pocket cost for prescriptions under Part D was $8000, and this year it is $2000. I assume Kevzara is similar to Actemra in regard to insurance.
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All of this is interesting. I started with Actemra injections about 6 years ago but I needed a waiver by the hospital to get it approved. I think there was some compassion involved because I only needed to pay a small amount for the injections. My injections were never submitted to Medicare but I only paid a small copay.
Over time, I was switched to monthly Actemra infusions. This was mostly because it was believed that infusions might work better than the injections. Now my infusions are submitted to my Medicare supplement but not Medicare itself. I don't pay anything for "inpatient infusions" even though I'm technically only in the hospital infusion area for 2 hours once every month. The hospital gets a sizable reimbursement from my Medicare supplement.
When I started Actemra --- Kevzara for PMR wasn't on anyone's radar. I think the success of Actemra to treat GCA opened up new options instead of lifelong Prednisone in my case.
I honestly don't know how my Actemra gets paid for. "Presumptive GCA" was part of it. Another part was "let's see if Actemra works if I was willing to try it" on the part of my rheumatologist. I was nearly unwilling to try it when people who didn't know anything about Actemra said it might be worse than Prednisone. Clearly ... Actemra has not been worse for me at least.
It is a shame that so much about medical treatments boil down to who is going to pay for it. Then it seems to hinge on creative reimbursement scenarios so everyone stays happy.
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You are correct with regards to the insurance. I started Actemra infusions 4 weeks ago. I just had my second infusion, yesterday. I have Medicare (not Advantage) with a supplemental plan. I chose the infusion route, since Medicare Part B would cover it after I paid my annual deductible. My Part D prescription plan would have required jumping through hoops to get it approved, with a high co-pay.
I started feeling a lot better about 2 weeks after the first infusion. More energy. I still wake up with some knee/shoulder/wrist aches, but they subside as I get moving for the day. I view Actemra has a life saver.