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Replies to "It was stressful for me waiting to see if the insurance company would approve the Actemra,..."
Polymyalgia Rheumatica (PMR) | Last Active: 2 days ago | Replies (30)
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It was stressful for me waiting to see if the insurance company would approve the Actemra, but I wasn't involved in any way with the process. My rheumatologist prescribed it and maybe provided justification, and after a couple of days the insurance company approved it. The reduction in the Part D cap from $8000 out of pocket max to $2000 this year helped a lot.
I never feel much difference from the Actemra injections. On the day of the injection I usually feel some really minor abdominal pains or sensations, and sometimes I feel a little tired the next day. But I know it's working since I've been able to taper the prednisone fairly rapidly with no issues.
Replies to "It was stressful for me waiting to see if the insurance company would approve the Actemra,..."
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In my experience the drug companies found a way around the $2000 out of pocket maximum. I have Medicare part D and no part D plan in my county would cover Kevzara. My estimated out of pocket cost for 2025 was $63,000. I called Medicare and my Part D insurer and they told me to have my doctor send in a Rx. He did that and the insurance company called and said my revised cost was $16,000. It appears that by saying they don't cover it they can pretty much charge what they want! Medicare told me that if a drug isn't covered the out of pocket maximum does not apply. I am off Kevzara mainly due to cost but it also wasn't allowing me to taper below 5 mg prednisone. It also raised my LDL cholesterol 50 points, from around the upper limit of normal at 130 to 180! My doctor advised that I start a statin. No thanks! Hopefully the cholesterol will come back down.