Pegasys/Ribavirin and Medicare

[jessie820]

Does anyone know of any programs that offer assistance with the coverage gap (donut hole) for people on Medicare?

I have been preapproved for Pegasys and Ribavirin but my Medicare Prescription Drug Plan through United Health Care has a $4,550.00 coverage gap and then 5% of the total drug cost approx $9200.00 a year.

The plan starts anew Jan 1st of each year so I’m looking at a copayment in the excess of $18,400.00.

[Bill1954]

The meds alone are in the USD $25,000 range per year; this only covers the interferon/ribavirin. If rescue drugs like Procrit, Neupogen or others are required, they can become *really* pricey. Office visits to the doctor, procedures such as liver biopsy, U/S scans etc additionally drive the cost up; we had a CPA track her hard costs and $65,000/year was paid out by either her or her insurance company. Others with more complex situations have reported costs in excess of $200,000/year.

Because the new Protease Inhibitor drugs will be used in conjunction with the current interferon and ribavirin, don’t look for them to be less expensive; far from it. The thing is, they might prove more efficacious, only requiring one treatment rather than multiple therapies that some genotype patients now require.

And the bottom line is that all these treatments remain cheaper than transplant surgery; this is probably the motivating factor for insurance payout to begin with.

Bill

I like your nickname, by the way :o)

[mestiza]

I have insurance, but of course I still have to pay about 30%.  upwards of 90,000 are you serious? Yeah, then It looks like I will have to wait for the new treatment.  I hope that'll be cheaper, but somehow I doubt it. Wow, I'm still in shock, i thought it was ging to be like 2,000 or even 5,000..  

[kittyface]

The meds and blood testing are very expensive, upwards of $90,000.  Do you have insurance?  If you don't you can get financial assistance from the drug manufacturer.  And some laboratories will provide discounted blood testing if you fall under a certain income group.

[mestiza]

Can you please tell me just how much does treatment cost? I'm sure it depends on lenth of treatment but a rough estimate would help, I had no idea it was that high.

[nygirl7]

I would try and give them a call anyway.  They were very generous with me - I wanted to extend treatment by six months due to a slow response rate and my insurance company said it was 'experimental (but they would cover a transplant later if I needed it)'.  So I was denied the meds by them however Comittment to Care paid 100% of them for me (technically I was insured though).

Maybe they could offer some advice on the situation that we dont know of.

If your doctor wants you to start treatment it would probably be best to try as hard as you can

I'm sorry God Bless the USA healthcare system...it's just so messed up. I  bet they'd pay all for a transplant though and look how much more that would cost!!!!

[JennyPenny2009]

I'm sorry the news isn't good. But I wish you luck. Delaying treatment until 2011 is probably no problem at all. Good luck to you.

[jessie820]

Thanks everyone for the information, even if wasn’t what I was hoping for.
I haven’t spoken with my Dr yet, I just got the notification last Monday from my insurance company. I’m thinking of asking my Dr to delay the start of my treatment until next January. I should then be able to complete the treatment in one calendar year.
Also under the new healthcare plan the donut hole is supposed to be reduced by 50% in 2011 may be that way I can reduce the cost to about two thirds.

[JennyPenny2009]

The company believes that the Genentech program is more generous than the Roche program was and have therefore decided to use that program. It's good for people who were denied help due to making too much money but it's a bummer for those folks who need help with co-pays etc. If I hear anything else I am more than happy to share it with everyone.

[Bill1954]

Oooh, this is interesting, Susie; I wonder if something has changed recently. I know some patient assistance programs in the past have stated they’ll deny assistance to insured, but on appeal they often will. Traditionally, both Roche and Schering Plough have provided assistance to uninsured as well as underinsured. I’ll be curious to see how this turns out—

Bill

[JennyPenny2009]

Unfortunately Genentech (Roche) will not be covering the meds for anyone with any insurance at all.  Here is a copy of their new program:

The Genentech Access to Care Foundation eligibility criteria for free Pegasys are:

Insurance: The patient must be uninsured or rendered uninsured by payer denial. GATCF does not provide free medicine to patients who have insurance coverage, regardless of the co-pay amount.

Financial: The patient must have an annual household adjusted gross income (AGI) of less than $100,000.00 (line 37 on tax return). Special consideration of financial criteria can be made for patients who are recently unemployed.

Medical: The patient must meet medical criteria. To apply for free Pegasys beginning September 1, 2010, physicians’ offices must submit two forms: a Statement of Medical Necessity signed by the doctor and a Patient Authorization/Notice of Release of Information signed by the patient. These two forms will be available online
at www.PegasysAccessSolutions.com or by calling 1-888-941-3331 beginning September 1, 2010.

[Bill1954]

Give the fine folks here a call. I was on Medicare and they covered my treatment 100%; no copays, deductibles, etc.

Pegassist (Roche Pegasys system): 1-877-734-2797

Commitment to Care (Schering- Plough PEG-Intron system): 1-800-521-7157

Good luck—

Bill

[kritikal]

Thats rough. Im not sure where, but some pharmacies have applications you can fill out for local charity coverage. There probably doing trials on new versions, see if roche will let you volunteer for new versions of the rna.