The patient copay assistance programs for Entyvio and others cover the cost of the medication only, which is by far the biggest cost and about
$10-12,000 for that medication. However, copay assist does not cover the costs incurred to have the medication given via IV to you, which are much, much smaller in comparison, they're usually $200-300 or so. Often my insurance covers nearly all of the infusion center costs and I end up with less than $20 out-of-pocket cost from it. Of course, all costs vary a lot by insurance policy.
For Entyvio, a typical bill would include:
- HCPCS Code "C9026 Injection, vedolizumab, 1 mg" and the number of Units reflects your dose.
- CPT Code "96413 Chemotherapy administration, intravenous infusion technique, up to one hour, single or initial substance." It's the nurse's time to give you the medication. The 2015 medicare reimbursement rate is $136.04, to give you an idea on payable cost (billable cost may be higher, before the insurance negotiated rate is used).
- If applicable, "CPT 96415 Chemotherapy administration, intravenous infusion technique, each additional hour, single or initial substance" would appear as a separate entry on the bill. Guessing it's not used for Entyvio, as the infusions are 30 minutes long. If they hit you for it, the 2015 medicare reimbursement rate is $27.93.
- You'll be billed for the Saline solution used, but it's typically less than $10.
- If you have an IV with a pump, then there can be a pump-charge within your bill. My infusion center uses gravity-fed IV's attached to the wrist or arm, so no pump is required. Not sure on that cost.
- If any pre-medications are given like Benadryl or Solu-Medrol (methylprednisolone), and I'm not sure they are with Entyvio, then you'd be billed for them, but their cost is minimal.
Some insurance policies have different and higher deductibles and copays for hospital outpatient procedures, then everything else. The first time you go you might hit the big deductible, but subsequently you've met it for the rest of the year (great if you later need a colonoscopy or something else done).