Will Medicare pay for ADT treatment?

[OldGuysRule]

I’m 62 and still working with good insurance. I recently started Lupron and Zytiga. I plan on retiring at 65. Will Medicare pick up the cost for that treatment?

Thanks

[Tall_Allen]

Medicare+Supplemental will completely cover the cost of Lupron shots because they are given by a doctor in his office. However, pills like Zytiga are covered by a separate drug plan (Part D). Abiraterone is available as a low cost generic that may be cheaper than the co-pays on a drug plan.

[OldGuysRule in reply to Tall_Allen]

Thanks for clarifying

[Teacherdude72 in reply to Tall_Allen]

My Lupron shots are given in the Infusion Center but cost is covered the same.

[Alturia]

The lupron will be covered 80% by Medicare Part B because it is given as an injection by your oncologist. If you have a Medicare supplement plan that will pick up the remaining 20%. Zytiga is often covered by Medicare Part D if you purchase a Part D plan. But different plans cover different amounts. My first 90 day prescription of Zytiga cost me $430 while the 2nd 90 day supply cost $220 because I had satisfied the deductible.

[mrscruffy]

Just started Medicare this month, My first month of generic Zytiga is $350, that satisfies my deductible. Going forward it will cost me $95 a month. Cheaper than drinks and dinner with my wives. Hahaha

[cesces]

It will pretty much cover it if you get supplemental coverage.

Biden's new plan he just passed (called anti inflation something or other) caps your out of pocket cost for medications at $2000.

Some of those PC medications are crazy expensive. Not only are they now capped at $2,000 per year, the new law now finally lets Medicare negotiate drug prices... though one of the compromises they had to make was to roll this in over a period of years.

But you mudy STAY AWAY from those HMO type advantage plans!!!

[SeattleDan in reply to cesces]

This is all very good news and accurate, except that it’s important to know that the $2,000 limit doesn’t kick in until 2025.

[Tommyj2 in reply to SeattleDan]

Thank you for mentioning that Dan….It’s a very important piece of information. The opponents have a good long time to try to undermine it…. As to Medicare negotiating drug prices….we’ll just have to wait and see what kind of progress they make or if the drug companies will simply raise the prices to match the potential savings.

[Fightinghard in reply to Tommyj2]

and how much does gov pay for a hammer on the space station?

Cant wait to see the savings start in a few years if I am still around that long

[Foldem in reply to cesces]

I have an advantage plan and have very low cost drugs ($15 for Xtandi, many are free). I’d like to know why those plans are bad. Mine is fine.

[cesces in reply to Foldem]

When you decide to explore some of the options discussed here, they will block you. And you will have no option around them.

Basically you will be denied cutting edge care. That's how they keep their costs so low.

[Tommyj2 in reply to Foldem]

Wow…that is unbelievable!! What Advantage plan do you have??

[Foldem in reply to Tommyj2]

Kaiser in California.

[swwags in reply to Tommyj2]

The statement he made requires context. It's an over simplification of how MA works. See my response below to Foldem.

[swwags in reply to Foldem]

Medicare Advantage Plans are not Medicare. They are private insurance. They use what is referred to as "narrow networks" which simply means a small geographic location relative to where you live. In that regard, if you live in let's just say Sacramento but you want to be treated @ UCLA Berkley, this would be out of your network and not covered. If you live in a large metro area, usually not an issue if you get care in said area. If you're in the suburbs or outstate, you may have trouble. With regard to claims coverage, unless your insurance summary plan document specifically states a specific treatment is not covered, it must be covered unless it is considered experimental or not medically necessary. It can be hard to get authorizations for services, even in your network. This is just a simple summary. The devil is always in the details.

Here's a bit more info:

medicarefaq.com/faqs/why-me...

[Tommyj2 in reply to swwags]

Thank you for the clarifying response but I’m a bit uncertain as to why you sent it……. I had just asked Foldem who carried his MA plan as the drug prices he quotes are remarkable…. I’m quite aware of the structure of MA’s having been a Medicare counselor for a few years ( 3 yrs out I’ve forgotten quite a lot…). That said….thanks for taking an interest.

[swwags in reply to Tommyj2]

I was replying to Foldem

[Tommyj2 in reply to swwags]

so you were…missed that….sorry

[dhccpa]

AARP Walgreens Rx plan D under Medicare has generic Zytiga for about $110/month (I live in Florida).

[Fightinghard in reply to dhccpa]

After paying max deductible, xtandi costs about $650 month on the aarp walgreen plan in fla

[dhccpa in reply to Fightinghard]

Thanks for the tip. I hope to do abiraterone acetate first, but not there yet.

[Explorer08]

My ADT drug is Orgovyx (Relugolix). It is covered by Medicare Part D. I pay $72.30 copay per month through a specialty pharmacy.

[Tommyj2 in reply to Explorer08]

That’s quite a good price. Are you on a Medicare advantage plan or straight Medicare with a separate Plan D. Who is your carrier?? What part of the country??

[Explorer08 in reply to Tommyj2]

I am on United Healthcare Medicare Advantage PPO. My meds are through OptumRX. In Colorado.

[Tommyj2 in reply to Explorer08]

Thanks for the info….hope the prices remain as good in 2023

[dixiedad]

I have Medicare Advantage with UHC through AARP and am very happy with it. No monthly premiums, dental coverage, drugs, etc. I pay nothing for Trelstar (ADT) injections. No co-pay for PCP, $25 co-pay for specialists.

[Lewellen]

I have a Medicare Advantage plan (healthpartners in MN), backed up by Medicaid (for employed persons with disabilities).

For a low income "retired" guy who was on disability for 20 years before hitting retirement, this combination of government services has saved my life more than once and my sanity even more often 😂.

Coverage has been extraordinarily good. My only trouble was trying to get an out- of- network 2nd opinion at one point. It was technically possible but in practice never happens.

[V-Man]

I"m also in SoCal, with Kaiser ... 67 yo, Stage 4 crMPCa diagnosed 4½ years ago. have been on multiple ADTs, 2 cycles (28 infusions) of docetaxel, referred now to get Pluvicto at UCLA. I've received incredible care and in a special Med Financial Assistance (MFA) program w Kaiser ... on Medicare, limited resources. No copays, no drug costs for year. I don't what I"d do without Kaiser. I reapply annually. An over the phone approval process.