Price of Medicine

[TET6489]

Does any one know if Medicare helps pay on any of these high price cancer medications

[jimreilly]

I just know that Medicare doesn't pay for any of my medicines, and what is paid comes out of the supplementary insurance coverage/drug plan that I have through my former employer, and I thought that was the way it worked.

[vandy69]

Medicare covers drugs like Lupron or Firmagon injected at a physician's office. Oral drugs like Zytiga and Xtandi are typically covered by your Part D Prescription Drug plan, as they are sent to your home from a Specialty Pharmacy. I have had good results with Humana's drug plan, as in 2015 my "retail" cost of drugs was $247,000 and I paid, out of pocket, $15,000. Monthly premiums are about $18.00!

[Neal-Snyder in reply to vandy69]

If anyone is in a position to join Kaiser with a good employee plan, you may do well, although not necessarily quite as well as what I'm getting. I was a State of California employee, & as a retiree I'm in the Kaiser Senior Advantage plan with excellent coverage. Zytiga costs me a few bucks a month. Lab tests are free. I know people who join Kaiser independently don't do AS well, but I think they do fairly well.

[Hidden]

Hi

Yes but as noted you need a separate Part D plan. Medicare Part A covers hospital, Part B covers outpatient services, Part D covers prescription drugs but you need to enroll in a plan. Open enrollment is going on now, however if you had not previously enrolled in a plan Medicare may add a permanent penalty (increase cost) to the plan that you choose.

There is a fairly complicated formula on how much they will pay and how much the co-pay is etc. Once you reach a certain amount of out of pocket costs then you wind up in the catostopic cost category, so with the expensive drugs you will most likely wind up out of pocket at first and then the co-pay reduces, However the out of pocket is a annual benchmark and it resets at the beginning of each year so you may have to pay the higher co-pay each year.

There are many different plans available but the basic formula is the same.

I know this may be confusing and it certainly is to me but it is run by a federal agency and they have a lot of rules and regulations..

I hope this is helpful

Bill Manning

[TET6489 in reply to Hidden]

Thanks. I have a part D that has been good but not used yet for those expensive drugs. Before I got on Medicare took one lupron and had to pay a good part. Thanks

[herb1]

Tet,

Before you continue with your Drug D plan, you might want to have a "consult" with a vendor (private, not govt, so be careful) who is selling one of the Advantage plans. These usually combine Medicare A, B, and D in one. They may offer some cost advantage but you may lose some of your doctor and hospital choices.

If you stay with a plain ole "D" plan you will have to pay the cost into/through the donut hole, but I think once you get into "catastrophic" coverage, your cost is limited to 5%. My own estimate with Zytiga is a total annual cost of about $9500; still not peanuts.

You also might want to look into programs some of the drug vendors offer to reduce your costs. I don't know if that can be combined with the D plan.

Good luck.

herb s

[JoelT in reply to herb1]

Herb, Are you aware of any "private" consultants who don't have any skin in the game?

Joel

[herb1 in reply to JoelT]

Joel, Of course not! That's why I did point out the need to be careful.

herb

[Sisira in reply to JoelT]

Bitter truth about the reality all over the world!

I fully appreciate your having hit on the head of the nail.

Sisira

[bjorner3]

Does any one have experience with your urologist who is not participating in Medicare and then recommending first casodex (five weeks and not covered) followed by lupron injection (not covered supposedly)? I am told the part D won't cover the lupron (because physician non participating?) and supplemental (BC/BS) won't cover any part of Lupron injection because if they did they would be considered primary not secondary (which they technically are). End result is no coverage for lupron for me. (Radical prostatecotmy, stage 3b, PSA pre-op 15.99, post op PSA 5.65, age 65) Am being told most places charging $7,000 for lupron injection (have hear this from patients that paid it or at least were charge it) but will charge me $2,000 in his office. there are so many different price levels apparently being charged for lupron (am in US). Any direction is appreciated! Is it possible to file for a reconsideration with Medicare to provide payment for lupron? Anyone done this successfully? Apologies for length of reply!

Bjorner