Oops. Not great insurance for treatment

[524nurse]

Well at least we have Medicare and are with kaiser😉. We have basic and no d. Kinda pricey. But I know these expenses are going to increase. We will add Medicare d and move to their advantage program at the end of the years. Any suggestions on supplements or tricks of the trade to get better coverage. We probably won’t drop kaiser🤭

[Hex40]

I was advised with a chronic illness avoid the advantage plans. Medicare for me starts 1/1/2020. On the plan Ds verify they cover the drugs you are taking or may take. You may also get dinged a bit by not signing up for D at the beginning.

[cujoe]

Like me, you may find that if you didn't take Part D when your reach 65, you will pay a premium "penalty" for EACH year you were not covered. (Same applied to basic Medicare.)

Another pay me now or pay me later provision of our "best on the planet" health care system. I well remember hearing an interview when Plan D was being legislated - no doubt written entirely by the pharmaceutical and insurance lobbyist in DC- that the long-term cost implication for Plan D drug benefits would quickly exceed those for basic Medicare. And here we are, with most new patent-protected drugs often exceeding $100k per year. And since facility-administered drug are covered under basic Medicare (at little or no cost to the patient - for Medicare approved drugs, that is), is it any wonder that all new drugs are oral drugs and, since patient-administered, covered under the MUCH greater-cost-to-patient Part D?? Just like the financial crisis 10 years ago (and the next one yet to come), who could have ever seen it coming??

A prime example of the best legislation money can buy. This is from Wikipedia:

Former Congressman Billy Tauzin, R–La., who steered the bill through the House, retired soon after and took a $2 million a year job as president of Pharmaceutical Research and Manufacturers of America (PhRMA), the main industry lobbying group. Medicare boss Thomas Scully, who threatened to fire Medicare Chief Actuary Richard Foster if he reported how much the bill would actually cost, was negotiating for a new job as a pharmaceutical lobbyist as the bill was working through Congress.[30][31] 14 congressional aides quit their jobs to work for related lobbies immediately after the bill's passage.[32]

Anyone with a reasonable intellect should be uniformly dumbfounded at the Rube Goldbergish nature of Plan D, with its multi-tiered drugs structure (that varies with insurance provider and from year to year), and the unfathomable coverage "donut hole" that are designed to get anyone who can pay to the yearly catastrophic coverage level that, last time i checked, guaranteed about $10k out-of-pocket drug costs for individuals.

To see Plan D in all its wonder, look here:

q1medicare.com/PartD-The-20...

Good Luck - We all need quite a bit of it . . . & Be Well - cujoe

[524nurse in reply to cujoe]

I feel like I’m back in college flunking out so much to learn in such a short time. You’re knowledge is impressive!!

[cujoe in reply to 524nurse]

All learning is via the "school of hard knocks". I'm currently working on a PhD. You are now officially enrolled in our fine school and currently earning daily credits. Be Well - cujoe

[j-o-h-n in reply to cujoe]

Piled High & Deep.

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 05/02/2019 8:26 PM DST

[Magnus1964]

If you are concerned about expensive Pca drugs you can contact the manufacturers. If zytiga contact Jannson Oncology, if xtandi contact Astellas. You can also contact the Patient Access Network. You Uro should be able to help with this.

[ctarleton]

Howdy 524nurse. Welcome. In which Kaiser region/city are you getting the prostate cancer care? Some men work within the Kaiser system to get to better imaging facilities and better expertise via referrals from their local Kaiser doctors, particularly for some types of advanced cancers. For example, in the Northern California Kaiser region, some Kaiser advanced prostate cancer patients might get a 2nd opinion referral here, while still receiving routine stuff at the home facility.

mydoctor.kaiserpermanente.o...

(Click the "Show More" on the "About Me" section.) She formerly worked with the very knowledgeable research staff at UCSF, across the San Francisco Bay from Oakland, CA.

Charles

[524nurse in reply to ctarleton]

Hi there. We’re in the Seattle area. Thanks so much for the link!!

[monte1111 in reply to ctarleton]

I shall keep that in mind.

[407ca]

For myself, in Florida, I chose traditional medicare part B with an "F" plan, and a part D plan through AARP . I like the ability to not need prior approvals and the ability to go almost anywhere I want. Everyone accepts these plans. They do cost more than advantage plans but it works for me well.

[sjc2 in reply to 407ca]

We will be moving to Florida when hubby gets on medicare and are very concerned about the cost of drugs he may need on this horrible journey! The "Donut Hole" scares me the most, we will be on a fixed income, but not so low to get financial aid. With all the plans you have, do you have a high out-of-pocket cost per year with your cancer care?

[407ca in reply to sjc2]

SJC2

My out of pocket costs for a year are nearly zero, excepting the insurance costs. I take only a couple common prescription meds so I never make the donut hole. At some point I know I will get there if I do ADT but at least for now it is not a concern. My AARP part D is $28/ month.

[sjc2 in reply to 407ca]

Thanks! Do you have a maximum out-of-pocket (the most you would ever have to pay each year) and do you mind telling me what that amount is?

[Survivor1965]

I was lucky ( I guess ) I was able to stay onCOBRA thru my employer indefinitely. It’s a state cobra vs a federal cobra so state law says I can stay. I opted out of Medicare in February. Just the donor hole of $5100, AND, the 5% copay ( my meds are $20,000/mo) which would be $1000/mo make it ridiculously expensive ($17,000/yr) And that’s just the meds. My cobra is only slightly cheaper but it has caps. Even still, we spent $27,400 in medical last year! It’s killing us

[RayF]

Something to look into: Kaiser told me that they have a grant for patients with certain diseases that covers co-pay. I don't know if that covers all areas or not. I am in VA. Ask them about it.

[524nurse in reply to RayF]

Hi there. We did check into that. But make 400 dollars a month to much. And the eventual meds will be 2 k a month. They only take monthly income as a factor. Not living expenses. Don’t get me started on how unfair this is.

[DenDoc]

I am in Kaiser Medicare Advantage plan in Colorado. It has been wonderful. My out of pocket expense is capped at $2000 which I hit in July last year. The rest of the year was no copays. In-0ffice administered medications are charged at minimal copay and go toward that cap. Last year KP Medicare billed $344,000 in my name and still I only paid $2000. The drug plan currently is covering Xtandi(Enzalutamide) for $30 per month I get $10,000 worth of drug. No plan D ever! Any drug that is FDA approved is covered.

Talk to KP Medicare Sales in Seattle. My understanding was that you can sign up for Advantage any time of the year based on Kaiser's quality ratings. Seattle should be the same rules since it is a federal contract, not a state run option.

[sjc2 in reply to DenDoc]

Dumb question, is Kaiser just another insurance choice with Medicare?? Can we get it Florida? We will be moving to Florida when hubby can retire and go on Medicare. Trying to figure out the BEST plans, so we can actually afford his meds and any cancer treatment/tests he'll need. The unknown scares us, we want plans that have an out-of-pocket cap, so we'll know the MOST we'd have to pay each year! Your plan sounds GREAT and then I read abmicro's post and I'm all confused again!!

[DenDoc in reply to sjc2]

No, Kaiser is only available in states where they operate. Currently, Northern and Southern California, Oregon, Washington, Hawaii, Colorado and the D.C metro area.

[sjc2 in reply to DenDoc]

Thanks, but bad news for us!! Glad you have such a great plan and pray you will do well in this battle!

[monte1111 in reply to DenDoc]

Wikipedia adds Virginia, Maryland and Georgia. Did not know that. Thought they were everywhere. Who knew.

[524nurse in reply to DenDoc]

Hi there hope you’re continuing to do well!! My question is how did you get your xtandi covered without Medicare d and it being an oral medication. They only cover injections for us. Thanks

[DenDoc in reply to 524nurse]

There is no plan D when you are in a Medicare Advantage Plan that includes prescription drug coverage. All FDA approved drugs are included.

[524nurse in reply to DenDoc]

Thanks we’re on advantage basic. Do you mind me what plan you have. Thanks so much

[DenDoc in reply to 524nurse]

My card does not designate but I think it is a Gold plan equivalent. I am a retired employee so it is a retiree package which is usually the highest option.

[abmicro]

Endless telemarketing and TV ads asking you to sign up for Kaiser HMO at zero monthly cost, so I did when I got disability approved. I was on kaiser SCAL HMO Medicare Advantage for a while and and could not switch back to a PPO even during open enrollment. Watch out for that law to get you bad. I was able to switch to a PPO when I moved to NCAL because I fell into a special enrollment caused by moving out of area. Glad to be out of Kaiser.

I now go to UCLA, Stanford, and UC Davis for my care. If I want to fly to NY, I can even get opinions there.

[ImaSurvivor1]

I would think long and hard about staying in Kaiser (or any other HMO) on the Medicare Advantage program. I was in Kaiser for 35 years. Always got excellent treatment, although like anywhere else, you have to find out who the best doctors for you are. Kaiser has very good doctors, and you can get very good treatment for things for which the treatment is obvious. By that I mean if you break a leg, they'll fix it just fine. If you need a baby delivered, you'll get excellent care. If you decide to have your prostate taken out, they have excellent surgeons. There are clear "standards of care" for those things. The problem comes with things like recurrent cancers, where it's not so obvious what treatment will work for you, and what you can do if it's not available at Kaiser. In my experience, if you want the "standard of care", you'll get it and it will be administered well. On the other hand, if you have done your homework and want something other than the standard of care, you are likely to be out of luck. Kaiser gets paid a certain amount per patient, per month by Medicare, whether you need no treatment or you need a very expensive procedure and very expensive drugs. If it's a procedure they offer, great, but you aren't going to get what Kaiser doesn't have. It's extremely rare that you'll get referred to anyone outside of Kaiser. Often you'll find the only second opinion you'll get is from another Kaiser doctor who has the same restrictions on what he/she can offer as the original doctor. Again, in most cases that's all you need, but if you're fighting a cancer recurrence, you probably won't get the tests that can tell if the drugs they're offering you will work in your particular case. They may try all the various drugs one or two at a time in sequence, changing them to another when they don't work. In my opinion we need to be able to go wherever the treatment or drug is that you and your doctors, wherever they are, think will work for you -- not just the standard of care. My medical oncologist at Kaiser wouldn't budge on trying anything else. I got out of Kaiser and have a good secondary insurance plan, and I can go to Mayo, MD Anderson, City of Hope, or wherever there is a treatment that the clinical trials and the medical journals show is working for patients with my disease and my genetics. And that's what I'm doing.

[sjc2 in reply to ImaSurvivor1]

May I ask what you switched to and what amount of out-of-pocket cap (if you have one) you have yearly? Thanks!!

[ImaSurvivor1 in reply to sjc2]

I switched to traditional Medicare. Fortunately I also have good secondary coverage from my past employment that covers most of the 20% that Medicare doesn't cover.

[DenDoc in reply to ImaSurvivor1]

Not my experience at all. I have a very complex recurrence and my medical oncologist is on top of everything new. When I was biopsied and found to have a transformation to Small Cell Cancer he ordered tumor genetics (at no cost to me) and when my cancer reactivates the genetic testing will guide the treatment.(Looks like Olaparib next)

[ImaSurvivor1 in reply to DenDoc]

That's great. Maybe various Kaiser regions handle things differently.

[j-o-h-n]

I guess it's cheaper when the reaper digs us deeper.

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 05/02/2019 8:38 PM DST

[R410a]

Be careful on switching plans, with pre existing conditions. You are only guaranteed acceptance once. Research this thoroughly.

[jmurgia in reply to R410a]

In New York state there is no medical underwriting for Medicare Supplement plans. You can switch despite having preexisting conditions. The articles on the internet do not usually mention this as the articles are usually not state specific.

[524nurse]

😳

[abmicro]

Good advice and a good oncologist can make the difference between surviving 5 years and surviving 20 years or more. I could not find a good oncologist at Kaiser and had to get out.

I had to interview many urologists to find the right one to do my prostate surgery in Feb 2002, and even went into the database and wrote down the top 3 who did not have too many reports of issues after surgery. (That was over 17 years ago so I am beyond the statute of limitations for unauthorized access to that database, and I no longer work for Kaiser so I dont care.)

He was the best Urologist I ever met, but he retired 10 years later. He had no problems following outside advice and giving me an off label prescription, as long as recommended meds "caused no harm".

I looked for an oncologist at Kaiser, but could not find a good one. One said don't worry, Kaiser pays for hospice. He was an idiot. I finally flew to the east coast and started seeing Dr Charles E Myers and eventually moved to NCAL and got out of Kaiser. Meyers also retired but I now have some good university oncologists that I can talk to at UCLA, Stanford, and UC Davis.

Kaiser HMO is history, and I am way beyond anything Kaiser can do for me. Will NEVER go back to a Kaiser HMO, even at zero cost. Ignore the ads on TV.

[ImaSurvivor1 in reply to abmicro]

Abmicro, Would you share the names of good oncologists you've found at Stanford, UCLA, and UCDavis with this refugee from Kaiser? Thanks much.

[abmicro in reply to ImaSurvivor1]

I am seeing Dr Galatin at Stanford. He is very diverse in his knowledge. There may be oncologists more specialized in just prostate cancer at Stanford. If I need chemo, I go to UC Davis Dr Pan, only because it is close to where I live. I dont know good oncologists at UCLA. I am being treated there on a clinical trial, and they are not oncologists. They are clinical trial doctors.

[monte1111]

I pay $20 mo. for Kaiser Senior Advantage No. Ca. plus $20 mo. for dental/vision. (The dental plan choice of dentists is horrible, and I will probably just pay cash to long time dentist.) Being one guy on Social Security I qualify for patient assistance. Do not throw rocks at me. I get SOC. I can't afford to fly here and there for treatment. We are all in leaky lifeboats, but some of us do have bigger boats. Enjoy.

[annjohannsen]

For Zytiga I was referred to Johnson and Johnson for financial assistance. It was very easy to apply and my husband was accepted. I can give out the phone number if you would like it.