July 2, 2015

Rytary: Will My Insurance Cover It? Even If It Does, Will It Be Worth It?

Rytary is a new formulation of extended release (ER) carbidopa/levodopa. It differs from earlier ER meds because it contains special beads designed to dissolve at different rates in the stomach and intestines. Designed to provide longer-lasting benefit for those of us with Parkinson's disease, it was approved by the FDA in January.

My neurologist wrote me a prescription for rytary more than a week ago. But my CVS pharmacist said my insurance company wasn't covering it. Without coverage, the new drug would cost $978!

I'm covered by AARP MedicareRx Preferred, administered by UnitedHealthcare, the country's largest health insurance company.

My neurologist is on vacation, but should return by the end of next week. So I called UnitedHealthcare to learn how to secure coverage for Rytary. Here's what I discovered:

Formulary Exception For a New Drug
Rytary is now considered a "non-formulary" drug under my plan. To get that designation changed, we'd need a formulary exception. The insurance rep told me there were two ways to expedite such an exception.
  1. I could have a prior authorization form sent to my doctor, who would need to respond within 72 hours. 
  2. My doctor could request the exception by phone. 
Under the circumstances, I chose option two. I'll provide my doctor with the phone number.

$$$ Issues
UnitedHealthcare's helpful rep advised me that rytary would be a Tier 4 co-pay... if the exception is approved. A 30-day supply would cost me $85 at one of the plan's preferred pharmacies (like Walgreens or Walmart) and $95 at other pharmacies, like CVS.

If I end up in Medicare's "donut hole," I'd have to pay more. In 2015, the donut hole begins once my plan and I have spent $2,960 for covered drugs. Beyond that threshold , I'd have to pay 45% of the plan's price for covered brand name prescription drugs. But the Medicare price would be lower than CVS's $978 quote.

Yesterday, I picked up a new prescription for the old ER version of carbidopa/levodopa. My co-pay? $6.31!

Interesting Decision on the Horizon
Even if we get the formulary exception, I'm not sure I'll use rytary.

I switched from the regular carbidopa/levodopa to the ER version about a month ago. Since then, I'm no longer getting the scary "off-period" blood pressure spikes I regularly experienced on the regular carbidopa/levodopa. My incontinence is now more under control, and I'm feeling better generally.

Even so, this ER variety I'm taking isn't perfect. Two neurologists have told me their patients have found the new ER levodopa/carbidopa version occasionally erratic, reporting episodes of its not working at all. I recently experienced such an incident.

My research on patients' reactions to rytary has uncovered a decidely mixed bag. Next week, I'll share those responses from users.

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