The High List Price and Out-of-Pocket Reality
Krystexxa (pegloticase) is a specialized medication for adults with chronic gout that is not adequately controlled by other therapies. It is administered via intravenous (IV) infusion every two weeks. The high list price reflects the cost of developing and producing a complex biological medication. For example, some sources show the price for a single milliliter vial can range from approximately $29,000 to over $31,000. This translates to a staggering potential annual cost of tens of thousands of dollars if paying out-of-pocket.
It is crucial to distinguish between this sticker price and a patient's final financial responsibility. Due to insurance plans and financial assistance, it is highly uncommon for a patient to pay the full list price. The actual out-of-pocket expense is determined by a complex interplay of insurance benefits, deductibles, copayments, and coinsurance.
Navigating Costs with Insurance and Patient Programs
Because of its high cost, Krystexxa is often covered under a patient's medical benefits (like Medicare Part B) rather than a standard prescription drug plan. For those with commercial insurance, the manufacturer's patient support program is the most important tool for managing costs.
How the Amgen By Your Side Program Works
Amgen, the manufacturer of Krystexxa, provides comprehensive support through its "Amgen By Your Side" program. A dedicated Patient Access Liaison (PAL) helps navigate the financial complexities. The program offers assistance tailored to different insurance situations:
- For commercially insured patients: Eligible individuals may qualify for a copay program that can reduce their out-of-pocket cost for both the medication and the infusion administration to as little as $0. Eligibility is subject to specific criteria, and the offer is not valid for government-funded plans.
- For patients with government-sponsored plans: Those with Medicare, Medicaid, or VA coverage are typically ineligible for the commercial copay program. However, a PAL can help identify and apply for financial assistance from independent foundations that may help cover costs. Medicare Part B, for example, typically covers Krystexxa, but patients may still be responsible for a 20% coinsurance.
- For uninsured or underinsured patients: The Amgen support team can explore other avenues to get the medication at no cost or a significantly reduced price for those with no or insufficient insurance.
Factors That Influence Your Final Cost
Several factors beyond the list price and patient programs can influence a patient's total cost for Krystexxa:
- Infusion Site: The location of the infusion can affect costs. A hospital outpatient setting may be more expensive than a private infusion center or receiving treatment at home. Your PAL can help coordinate the most appropriate and cost-effective site of care.
- Deductibles and Coinsurance: Even with insurance, you may need to satisfy a deductible before your plan begins paying. Coinsurance, a percentage of the total cost you are responsible for, can be significant without additional financial assistance.
- Prior Authorization: Krystexxa treatment almost always requires prior authorization from your insurance company. This is a process where your doctor provides documentation to prove that the medication is medically necessary and that you have failed on standard, first-line therapies. A PAL can assist with this process.
Cost Comparison: Krystexxa vs. Standard Gout Treatments
It is useful to compare the cost of Krystexxa with older, more traditional gout therapies. Krystexxa is reserved for complex cases where other drugs have failed, a fact that contributes to its higher cost.
| Feature | Krystexxa (Pegloticase) | Allopurinol (Generic) | Colchicine (Generic) |
|---|---|---|---|
| Cost | Very High (Potentially $60,000+ per year list price) | Very Low | Low |
| Mechanism | IV infusion to break down uric acid | Oral medication to reduce uric acid production | Oral medication for acute flare-ups |
| Administration | Intravenous infusion every two weeks | Oral tablets daily | Oral tablets for flare-ups |
| Patient Population | Severe, uncontrolled, chronic gout | Standard, first-line treatment for most patients | Acute flares and prophylactic use |
| Patient Responsibility | Highly dependent on insurance and copay assistance | Low, or standard copay/coinsurance | Low, or standard copay/coinsurance |
Conclusion
For patients with severe, uncontrolled gout, Krystexxa can be a life-changing treatment when other options have failed. While the list price of the medication is very high, the actual financial burden on a patient is a separate matter. The cost is manageable for many through insurance coverage and the Amgen By Your Side patient support program, which can potentially bring the copay for commercially insured patients down to $0. Working closely with your healthcare provider and a Patient Access Liaison is the best way to understand your specific costs and navigate the financial aspects of Krystexxa treatment.
