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Does Medicare Cover Krystexxa?

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By Daniel Petkevich
Nov 18, 2022

Yes, but how it's covered could save you money

For many Medicare beneficiaries looking for chronic gout treatment, Krystexxa (Pegloticase) can be a critical medication. If you have tried other forms of treatment for your gout with little success, Krystexxa can be a path to a more pain-free life. Krystexxa might be covered by Medicare Part D, and it will be covered by Medicare Part B. But which option saves you more money out-of-pocket? Let's dig deeper.

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What is Krystexxa?

Krystexxa (Pegloticase) is an FDA-approved treatment for chronic gouty arthritis. It works by breaking down uric acid in the bloodstream, which can reduce inflammation and pain associated with gout. Krystexxa comes in a powder form that is dissolved in water and injected into muscles or under the skin. Other forms of treatment for gout include diet and lifestyle changes, medications such as allopurinol or colchicine, and joint injections of anesthetic or steroid medications. If these other options do not work for you, Krystexxa might be able to help.

Does Medicare Cover Krystexxa?

Medicare Part B covers the cost of many drug therapies, including the cost of Krystexxa. If you have a Part D prescription drug plan, your plan might cover a portion or all of the cost for drugs like Krystexxa, depending on what is in your plan's formulary.

How to get Medicare to cover Krystexxa

Medicare Part B covers the cost of Krystexxa, but you must meet certain criteria to be eligible for coverage. You must have a doctor's prescription for the drug and your doctor must specify that it is medically necessary, as well as provide documentation supporting their medical opinion. Your doctor also needs to certify that you tried other treatments.
If you're getting coverage for your Krystexxa on Part B, you might be responsible for 20% of the cost that Medicare does not cover. If you have a Medicare Supplement plan, that could cover some or all of that 20%. The average cost of could run as high as $60,000 per year, so that 20% could be as much as $12,000.
Medicare Part D might also cover a portion or all of the cost for drugs like Krystexxa. Contact your insurance plan provider to find out and ask if they cover Krystexxa in their formulary.

What are the side effects of Krystexxa?

Krystexxa can cause side effects, including nausea, vomiting, abdominal pain and heartburn. Other possible side effects include anemia, elevated blood pressure, low white blood cell counts and allergic reactions such as itching or hives. It's important to talk to your doctor about any potential risks before starting treatment with Krystexxa.

How to find a doctor who can prescribe Krystexxa

It is important to find a doctor who understands how to use Krystexxa properly and will monitor your progress while you are using it. Ask your primary care provider if they know of any doctors in your area who specialize in gout treatment. You can also search online for physicians who specialize in gout treatment or contact the drug's manufacturer, Savient Pharmaceuticals, to find a doctor near you.

Tips for living with gout

Living with gout can be difficult, but there are some things you can do to make it easier. Eating a healthy diet and exercising regularly can help reduce inflammation and pain associated with gout attacks. Drinking plenty of water helps flush through the uric acid crystals in your system that causes the pain. Avoiding or reducing processed foods, high-purine foods, and alcohol can help reduce the frequency of gout attacks. Lastly, talk to your doctor about other forms of treatment that might be more suitable for you.

Takeaway

In conclusion, Krystexxa (Pegloticase) is an important treatment option for those with chronic gouty arthritis who have not had success with other forms of treatment. Medicare Part B and Part D might cover some or all of the cost of your prescription. You should check in with your doctor to see if Krystexxa is right for you and your plan provider to see how you can receive coverage through Medicare. This content is for informational purposes only. If you have additional questions about your Medicare plan, call one of our experts today at 1-888-376-2028.

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