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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.
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There are many games that medical providers and insurance companies play. I worked as a medical case manager for a large insurance company many years ago. I could only do the job for less than 2 years. Most of my job was negotiating prices for "all inclusive" medical care. My specialty was mostly neurological conditions but sometimes that included complicated pregnancies and "preemies."
People would have a stroke or something and needed long term care. I would have to call medical providers and negotiate things assuming no complications from the treatment received. From the insurance company's perspective, I was supposed to get a per diem rate everything included. A medical case manager on the hospital side (usually a social worker) and I would discuss the price for things neither of us had any clue about. The hospital would say a price. The general rule was "cut the price in half and meet somewhere in the middle."
I think all the biologics are being scrutinized more because of the cost. The research is showing how effective they are assuming no complications. It used to be biologics were "experimental" and "not medically necessary" as the basis for denial. Now there are cost analysis being done. Complications from long term prednisone use might be more costly than biologics.
The following case study says it all.
https://www.statnews.com/2023/10/16/long-term-prednisone-steroids-ibd-side-effects-chronic-illness-alternatives/
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As the male counterpart but not with IBD--- I could have written this too.