Monthly co-pay costs for Firmagon/Degarelix shots on Medicare Advantage vs Regular Medicare USA?

[JPnSD]

I start monthly Firmagon injections (2-3 years estimated) next week and my Medicare advantage program just informed me that the monthly co-pay for this drug will be $429 ($5148/year). I was under the impression that drugs administered by a doctor didn't fall under drugs but treatment...and therefore would not be treated like tier 4 drugs. I am thinking of switching to Regular Medicare Jan 1...anyone have experience with this drug under that form of insurance?

[tango65]

I have regular medicare plus a PPO medigap and part D program and the maximun they can charge is $ 90 for 3 months supply. For Firmagon the PPO running my medicare part D has to approve it before hand. The doctors office needs to get the approval.

[JPnSD in reply to tango65]

Yep...went through approval...but they are applying it under drug coverage not therapy in my Medicare Advantage Program. Correction...they are applying under 20% for Part B...If I did it under Tier 5...it would be 33%

[Hidden in reply to JPnSD]

That’s a bunch of BS ..

[ellie2211 in reply to tango65]

How much do these plans cost a month? We are thinking about switching to a different plan in the future...one that will cover particpating in clinical trials when that time comes... Dad has medicare advantage at the moment....I don't know much about all the plans

[6357axbz in reply to ellie2211]

My BCBS plan F is $204/month

[6357axbz]

I have Medicare and a Plan F BCBS supplement policy. I never pay anything for Eligard or lupron or degaralix (I’ve had them all).

[JPnSD in reply to 6357axbz]

Thank you...looks like the way to go...an automatic $5100 savings per year. Correction...same 20% payment required under regular Medicare Part B. Your supplemental is picking up your co-pay.

[6357axbz in reply to JPnSD]

There has been talk of discontinuing Plan F options from Medicare supplement plan choices. It’s more expensive than other supplements but covers a lot more.

[Herman_PSA_OK in reply to 6357axbz]

Yes, they are removing Plan F and those folks will be grandfathered in. But, that pool of folks will diminish over time because they will raise the rates. Others will not have that choice. So, you are better off to switch now to Plan G which is cheaper and after you pay your annual deductable ( approx. $185 I recall) you have the exact coverage as Plan F. I have Plan F and was told Elegard would be administered in my urologist office. I'm off Elegard right now on a vacation/break.

[Herman_PSA_OK in reply to Herman_PSA_OK]

Correction to my post. I have Plan G not Plan F. So, the Elegard is covered.

[Kevinski65 in reply to 6357axbz]

Does regular Medicare pay for Zometa?

[mcp1941 in reply to Kevinski65]

I have regular medicare with a supplemental plan and Part D. I have had 3 zometa infusions and was not charged anything.

MikeP

[Buddy1950]

Have Medicare and blue cross supplement with Cigna drug. Medicare covers the whole cost as far as I can see. I get Firmagon once a month and no cost. Is the problem the advantage plan vs having medicare as you give up Medicare when going to the Advantage plans and they get your medicare dollars. If so, can you switch at the end of the year?

[maley2711 in reply to Buddy1950]

My undrstanding is that advantage plans are required to cover anyhting that traditional Medicare covers.....but does that extend to drug coverage..I don't know? why must Americans continue to be required to try to make sense of all these alternatives...must it be this convoluted?

[MarkBC in reply to maley2711]

I'm Canadian and read these discussions about various American health care options with complete bewilderment. I don't know how the average citizen there can figure it all out and not make costly mistakes.

[JPnSD in reply to MarkBC]

Too true. I am working with an insurance professional to try and map a path. Only way.

[VHRguy in reply to MarkBC]

Individual freedom of choice comes with responsibility. Being able to make choices does allow the ability to make bad choices. It also allows the ability to make the best choice for our particular situation. We already have far too much government meddling in our health care industry.

[JPnSD in reply to VHRguy]

I for one would prefer a system that wasn't based on profit motives of health care and big pharma.....and made the choices user friendly...rather than motivated by preserving profit for the industry we laughingly refer to as a "service" in the US.

[Want2no in reply to JPnSD]

I couldn’t agree more!

[Herman_PSA_OK in reply to maley2711]

Advantage plans are cheaper up front for sure. But, when you start getting sick and need to see the doctor of you choice, good luck. That's the trade off.

[JPnSD in reply to Buddy1950]

If I had a supplement/gap insurance plan...then it would be covered. But after 24 months of qualifying for Medicare...they won't sell you one if you need it! (Pre-existing condition)..imagine if they drop the present insurance coverages for the general public that prevent refusals for insurance if pre-existing conditions as is being proposed by the current administration.

[Buddy1950 in reply to JPnSD]

The other problem is getting out of network. Mayo said they would take Medicare and supplement, but advantage would be an issue with a lot of approvals. I think it is unfair all of this isn't easily understood by all. Blue cross person cautioned me from leaving the supplement as coming back may not be possible with pre-existing conditions and would cost more if it could be done. This in network stuff is an issue for all kinds of people and needs to be changed.

[Concerned-wife]

If you switch to regular Medicare, you will want to buy a supplement. And a Part D plan (for pills. ) You are smart to investigate this now as you need to do this soon under Open Enrollment. medicare.gov/supplements-ot...

Medicare.gov has many ways to help you and an online tool to choose a drug plan where you input your prescriptions. There are SHIPs in each state with counseling, not sure if they are all volunteers or not. You could find an Insurance broker who sells these plans...they are reimbursed by the plans. I find them helpful about the products they sell. AARP and most BCBS companies sell supplements and Part D Plans. With our supplement we are not charged for the injections, but the abiraterone pills Under Part D are exorbitant. In fact in the doughnut hole there, it appears it will be better to switch to the brand name from the generic next year, so we will be working on this research.

[Herman_PSA_OK in reply to Concerned-wife]

Do you ever notice that those Part-D plans drug prices are many times more expensive than using a Good-RX card and getting their discount. When you factor in your Part-D premiums plus the drug prices, it's cheaper to use the Good-RX card. For common drugs, that has been my experience. My CVS Care (SilverScript) Part-D insurance was just taken over by Aetna and they are raising the prices. Anyone with experience with Aetna out there?

[JRPnSD in reply to Herman_PSA_OK]

I checked my GoodRx at the satart of this...not available to patients as it is doctor administered and the only pricing the insurance will use is the designated pharmacy that they contract with (Optimum Rx in my case). GoodRx has saved me hundreds for drugs you can self administer.

Thanks

[HopingForTheBest1]

Make sure to go to medicare.gov and do a drug search, which will show you other plans and related cost of the drug. During Medicare open enrollment you can switch your Advantage plan for next year.

[jmurgia]

Hello JPnSD: I just looked up the costs for Firmagon on my medicare advantage plan (Excellus BC/BC Medicare Blue Essential including Part D drug coverage which is administered by Express Scripts). The cost for the initial dose (240mg) is $445.00. The cost for the subsequent 28 day doses is $190.00 each. The initial dose is considered Tier 5 (specialty) while the subsequent doses are Tier 4 (non-preferred brand name). Maybe you should have another look at exactly what dosage they gave you pricing for. What I don't know is whether this is covered under Part B (administered by a health professional) or Part D. My formulary is silent on this issue. The other consideration is who will be supplying the drug. My physician's practice will not administer any drugs they did not procure themselves. They should be able to contact your insurance company to get your cost. They may have to get prior approval from the insurance company anyway. If you switch to original medicare you will need to buy a standalone Part D plan anyway which will add to your costs. Original Medicare does not cover drugs. Open season for the medicare salespeople starts on the 15th so you should be able to get 2021 coverage and pricing details.

Joe

[JPnSD]

So...a summary of what I learned. Both Medicare and Medicare Advantage programs require that you pay 20% of the drug cost when done under Part B as it is Dr. administered. If you chose to go Drug coverage under Part D...cost is 33% due to Tier 5. If you are beyond 2 years from starting Medicare...(I am at 26 months) then you won't be sold supplemental/gap insurance because you have a documented pre-existing condition. Welcome to healthcare in America for seniors. Just imagine how much worse it might get if the present administration gets re-elected.

[jmurgia in reply to JPnSD]

If you go without Part D coverage for more than 63 consecutive days you will pay a penalty forever.

Tier 5 only for the 1st injection. After that Tier 4 I believe.

New York State has guaranteed issue supplement (Medigap) coverage.

One of the advantages to living here.

Thank God you're not taking Xtandi at over $3000.00 per month!

[JPnSD]

Correct...Tier 5 for 120mg and Tier 4 for the same drug at 80mg. I have been told I can qualify for a supplementtal plan if I move to a new district...preferably a different state! They make it so easy for us!

[Concerned-wife in reply to JPnSD]

I earlier shared a link from medicare.gov that during open enrollment you can switch. Have you checked during open enrollment. Which is soon.

[JPnSD in reply to Concerned-wife]

Yes...starts Oct 15-Dec 7...Started with an UHC agents weeks ago. Effective Jan 1 2021.

Thanks

[V10fanatic]

I'm glad to be on private insurance still. From what I've been told though I'd have to switch over to Medicare if I go on disability. I hope there is a loophole to keep me out of the Medicare Morass.

[jmurgia in reply to V10fanatic]

Just the opposite for me. I worked for a Fortune 100 company for 34 years. I basically worked until I dropped so I could have medical insurance for myself, wife and 3 children. Back in the mid 80's the company health insurance was free for single coverage. Near the end (2016) I was paying $385.00 a month for family coverage with a $3000.00 family deductible. It was a company self-insured plan whereas the company contracted with various insurance carriers (BC/BS at the end) over the years to administer the plan and the actual payment for care came from the company's bottom line. The plan was not subject to the usual New York State Insurance Department rules. The coverage was sometimes vague as it wasn't a standard issue BC/BS Plan, so when we called the phone reps were not completely familiar with the plan. I contributed the maximum to my HSA, all of which went to my deductible. In 2016 I went on disability and had COBRA coverage and then changed to Medicare in December of 2017, paying $134.00 or so a month for Part B and $0 a month for a Medicare Advantage Plan. When the COBRA for my wife and children ended we got together with a health insurance marketplace navigator and he arranged for Child Health Plus coverage for my youngest and Medicaid for the 2 others. He arranged for a Marketplace Exchange plan for my wife that had a small government subsidy. Still she paid $669.00 a month for single coverage. It turned out to be an excellent plan. She received a new $12,000.00 insulin pump for a $25.00 copay. She started on Medicare in January of 2020 and once we figured out the costs and coverage things have been rolling smoothly. The providers seem to know what Medicare will and will not cover. The pharmacy coverage for insulin and diabetic supplies was a little bumpy at first as they are considered Part B for insulin pump users and the pharmacy didn't know how to bill it. A call from the plan reps to the pharmacy straightened things out. We had to switch from a national chain to an independent pharmacy where we deal with the owner, who works behind the counter. When the BC/BS reps called the national chain they didn't fare any better than I did. With Medicare we now have a choice of plans and a fairly easy way to compare them. I did a lot of research before I started my plan and being happy with it we went with the same plan for my wife 2 years later. It hasn't been a "morass" at all for us. Coverage is better and overall costs are less.

Joe

[j-o-h-n]

Manhattan PROJECT plan KABOOM!!!💣💣💣

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 10/09/2020 7:37 PM DST

[JPnSD]

PAN Foundation can provide grants for those fighting prostate cancer and in need. Also...my primary care arranged for recoding the Firmagon and was able to reduce costs for 1st shot to $190 and maintenance dose to $90/month. Don't accept the first response you get as the ONLY answer. Our Medicare system is really imperfect!

[jmurgia in reply to JPnSD]

Cooperation from your healthcare providers is always a plus.