Medicare Part D insurance and Vyvgart coverage experience?
I've been recently diagnosed with a MG acute crisis; my neurologist suggested weekly Vyvgart hytrulo injections upon my release from the hospital.
I'm on traditional Medicare, and need to choose a Part D (drug) plan. Only 2 Medicare Part D companies in my ZIP code cover Vyvgart injections at all - HealthSpring ("Assurance Rx" or "Extra RX" ) and United Health Care ("AARP Medicare Rx Preferred from UHC"). All other plans would cost ~$1M/year out-of-pocket. I'm concerned because of comments that I've read indicate that both routinely deny coverage.
Does anyone have any experience with these companies to share? Medicare.gov chats and emailing CMS.gov have both completely failed to provide any useful information to date.
Thanks for the info, but it's not quite what I asked.
My neurologist originally *specifically* prescribed *weekly Vyvgart hytrulo at-home injections*; that would be under Part D. Under my current Part D (Wellcare), those are not covered at all and would run ~$1M out-of-pocket per year. She was unaware that it was quite so expensive and switched me to in-hospital infusions for now.
I'm hoping to find if anyone has experience with either of the 2 companies (HealthSpring, UHC) w.r.t. paying for the at-home injections. I've found references to a 87% denial rate by Part D companies for Vyvgart hytrulo at-home injections; the additional cost to even try those companies is between an additional $1700 to $2900/year for their Part D plans, so it's a cost-benefit issue.
My current in-hospital infusions of Vyvgart (HCPCS code#J9334, Inj efgart-alfa 2mg hya-qvfc) appear to be 80% covered under Medicare Part B with the remaining 20% covered under my Medicare Supplement G. It was considerable effort to ensure that these infusions would be covered by Part B, as I was given conflicting guesses (Part A? Part B? etc.) by the hospital staff. In a Chat session with Medicare.gov I was told that it would "not" be covered at all; while in a different Chat session I was told it "should be covered if medically necessary". CMS.gov has not yet responded to my requests for any records of the denial rate by those companies.
It is difficult to get hard numbers. Thanks again.I posted my experience with Vyvgart infusions. Vyvgart Hytrulo is an injection that still needs to be done in a medical facility, so Medicare Part B should still cover it. However, have you doctors office work with Vyvgart to ensure that's the case. If you don't have it already, you need to find a Medigap - Medicare Supplement plan - that covers all approved Medicare expenses to cover the 20% Medicare doesn't pay. I think most do.
Vyvgart is covered by Medicare Part B. Since Vyvgart is an infusion that needs to be administered in a medical facility, it is not part of Part D which covers prescription drugs you get at the pharmacy. However, Vyvgart is EXTREMELY expensive. Medicare Part B will only cover 80%. If you don't have a Medigap supplement plan that will cover the other 20%, you'll be in for a large bill. I've been doing Vyvgart through Medicare with Medigap insurance. While the numbers may vary depending on where you get the infusion, here is a rough breakdown of my EOB ( Explanation of Benefits). Make sure the infusion center accepts Medicare. The infusion center bills Medicare ~$50,000 - yes, you saw that correctly. Medicare approves ~ $20,000 and pay 80% - $16,000. My Medigap coverage pays the remaining 20% - $4,000. This is for ONE infusion. Vyvgart is a series of 4 infusions 7-10 days apart. So, each series of Vyvgart is paid at $80,000 - billed at ~ $200,000. Do 5 - 6 series a year and you'll see how costly this is - $1M+. Fortunately, I've had 10 or more infusions over the past 3 years and haven't had to pay anything. If I had to cover any of the cost, I wouldn't be able to take it, even if it's the best solution for me. Have your doctors office reach out to Vyvgart to get you approved. Good luck.
