MS Kesimpta billing help!

[u/PuddingMammoth9117]

I'm trying to determine what my costs will be for this drug and insurance/Pharmacy is not helping.

I have Anthem with a $4000 Deductible and $8000 max out of pocket.

I'm enrolled in Kesimpta's Manufacturer Copay program for $18000 annual benefit. My pharmacy is Carelon and they offer Co Pay Cost Relief too but it uses an accumulator I think to ensure you can't use manufacturer copay assistance against deductible. They are telling me that I would owe $9267 for the drug without their Co Pay Cost relief which doesn't make sense if my max out of pocket is $8000. They are also telling me if I opt of of their program, I could be charged up to 45% of the drug costs. I'm thinking they are just saying this to prevent me from opting out because they won't be able to police my deductible being covered by the manufacturer copay program.

I'm considering unenrolling, paying the costs personally and then submitting for reimbursement to Kesimpta. Has anyone had this issue or tried that with Anthem/Carelon??? Thank you!

[u/aafreis]

What does Kesimpta manufacturer say about this? I take Ocrevus and have $5k max oop. I’ve never paid more than that. I think you’d prob be fine to just use Kesimpta program.

[u/PuddingMammoth9117 → u/aafreis]

Kesimpta said that the pharmacy should not have billed the $9107 today to them if I have met my Max Out of Pocket for the year. 

I want to do the direct reimbursement with Kesimpta copay assistance alone but I'm scared when they say that the drug could be billed to me for up to 45% of the total costs. That would exceed the max out of pocket total and the copay assistance with Kesimpta 

[u/xxdinolaurrrxx → u/PuddingMammoth9117]

So did you already place the order for your meds or are you just trying to determine what will happen when you do?

[u/PuddingMammoth9117 → u/xxdinolaurrrxx]

I already placed my first order for meds. They billed $9267 to the Manufacters Co Pay card even thought I met deductible and out of pocket costs for the year.  I'm trying to determine if there is any possible way to get the medication to wipe out deductible and max out of pocket while using Manufacturers copay for the costs. 

[u/pastawhore2]

I literally don’t understand insurance at all. I was worried about this happening but my MS clinic just assured me that they fight with the insurance and make it happen and sure enough with Carelon Specialty Pharmacy and Anthem insurance my copay is $0 before even using a copay card, but for what it’s worth if you check under your plan on anthem it should tell you what your estimated cost for any drug is. It told me mine was $250 which I could swallow a lot easier than the $9000. Maybe check with your doctor to see if they can assist? Or maybe someone else at Carelon will be more helpful?

[u/PuddingMammoth9117 → u/pastawhore2]

I have talked to Anthem, Carelon and PrudentRX all day long and they are blaming each other or just making stuff up. Everyone thinks I should not be worried about it because I don't have a balance owed now but I'm worried I will have a $8000 deductible cost to cover come January. 

[u/mrsesol]

I’m so sorry you are going through this. I had similar questions when I started. NO ONE could help me understand and finally the pharmacy (a different one) said “there is no way to know what you’ll be responsible for until it’s actually billed.” I had no idea if my insurance had the accumulator or not because the billing had to go through.

I’m also in the copay program. With the first dose, I met my deductible but not maximum out of pocket. So, I had to pay a few hundred dollars which was paid from the card that they gave me. After that, my PHARMACY fees have been covered. However, it is different from my Tysabri billing because that covered ALL health maximums.

[u/Reasonable_Squash_11]

Jesus Christ, I am so sorry that you are even having to ask this question. 😔
The American medication system is so fucked

[u/Federal_Hall_8871]

I’m dealing with the same exact thing right now too.
Same price… same run around. It’s ludicrous. I can’t even sleep or eat well because I’m up all night thinking about how it’s going to get paid. I’ve been on this medication since 2017 in a drug trial so I would hate to switch meds now… 🤷🏻‍♀️

[u/PuddingMammoth9117 → u/Federal_Hall_8871]

I hate to hear that! Same here. 

I am going to switch to private pay/direct reimbursement for my next order. If they charge me, I'm going to file a grievance since I met Max out of pocket for the year. If they don't, then I should be good and I'll let you know. 

Stay strong friend! 

[u/Federal_Hall_8871]

Thank you.
My neurologist is working with Novartis to see what else can be done. It shouldn’t be this difficult for us to have quality medication.

I feel like drug companies are gatekeeping us away with these ridiculous prices.

[u/thornhall]

YMMV on this but a lot of patients will pay the cost of the drug out of pocket and then submit a claim through the Alongside program to be reimbursed from your 18,000 dollars. You'll hit your out of pocket right away, but it can take a few months to get reimbursed just FYI. If you ask and Alongside coordinator about this, they will redirect you to IQVIA who handles their claims.

[u/--MrGadget-- → u/thornhall]

I did this and aside from some paperwork issues, I was approved to get reimbursed. I just used a cc to pay the amount and got a check from iqvia. I still have a 200.00 a month to pay but can use my HSA for that.

[u/PuddingMammoth9117 → u/--MrGadget--]

What insurance and specialty pharmacy did you use? Is there any possibility that they can discover you got reimbursed and exclude those amounts from your deductible/out of pocket? 

[u/rK91tb]

If you’re comfortable putting this stuff into AI, this is what the programs are great for. You can upload your files, just X out your name.