Don’t Doubt the Expense of Gout
We’ve all heard about gout. It’s that sharp, hot pain and swelling that most commonly afflicts the big toe. One of the world’s oldest recognized diseases, gout was first identified by the Egyptians in 2640 BC and has been viewed as a lifestyle disease of the rich and affluent, primarily because of its connection to certain more expensive dietary habits. This “disease of kings” has been problematic for ages, with little change in the treatment options that first were identified thousands of years back – until a few years ago.
That’s when Krystexxa® (pegloticase) was made available. Krystexxa® is an IV treatment designed to lower uric acid levels, thus reducing or stopping gout flare-ups by working to remove uric acid crystal build-up from joints. But, it comes at a cost. Recent claims for this drug have presented as high as $91,000 per treatment, giving “the gout” the potential to create a more than $2 million-per-plan-year claim – indefinitely.
To save you a little time, the ICD 10s for eligible gouty members are usually in the ranges of M10 and M1As. If the claimant is being treated with Krystexxa®, chances are very strong that the medication underwent a prior authorization, so, we know the member has “earned” it through years of pain and suffering. To determine those at risk for high cost claims, look for charges with HCPCS code J2507 as an infusion about every two weeks.
Though the drug has been out for a while, the cost of using Krystexxa® has progressively gotten more expensive over the past few years with no change in the drug itself or to the way it’s delivered to patients. In 2017, some of the claims for the infusion were around $15,000 every two weeks. Then, in 2018, some ranged from $21,000 to $35,000 every two weeks. In 2019, most claims were still around that $21,000 to $35,000 range, but a few more recent claims have been as high as $91,000 each and, as such, if the drug is used consistently throughout the plan year, the health plan cost may exceed $2 million. This could come as a catastrophic surprise since most plan administrators probably are not automatically seeing multiple dollar signs when thinking of gout.
How can these costs be contained? Through awareness and review. Look at the claims and ask:
- Is the facility or provider in-network? Not only is using an out-of-network option a financial risk for the plan, chances are, the member has to pay more from their pocket as well.
- Is Krystexxa® available for Site of Care? A Site of Care option that directs members to a clinically appropriate but more cost-effective location to receive an infusion is not as popular for Krystexxa® to date.
- Could the Specialty Pharmacy contracted by the plan mail the Krystexxa® to the member who would then take it to the facility for administration? Always check both the medical and prescription benefits and especially if pharmacy is a “carve-out” and sold separately; in many cases, everyone is not on the same page, and opportunities need to be identified by an alternate source who is monitoring for opportunities under both benefits.
These are challenging times in the health care industry. Many pharmaceutical breakthroughs are helping people better manage or even be cured from ailments and diseases that have plagued them for years. But, more and more, these pharmaceuticals are coming at a premium price. Though gout was once associated with the wealthy and their consumption of rich food and drink, it now has a more wide-spread reach in our society – and it may require very deep pockets to cover the treatment costs.
Sources: “A Concise History of Gout and Hyperuricemia and Their Treatment, US National Library of Medicine and National Institutes of Health, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/, accessed January 2020; “Krystexxa pegloticase,” https://www.krystexxa.com/gout-treatment/#, accessed January 2020; “Aiming for $250M in Sales, Horizon Quadruples Force Behind Gout Med Krystexxa,” FiercePharma, accessed January 2020.