Erleada copay question

[Doodlebun]

I'm on Medicare D and I'm wondering what the copay would be if my doctor puts me on Erleada. When a person exits the donut hole they are in catastrophic coverage. This means that the copay would be 5% of total cost of the drug. Since the drug cost is $15,000 a month, then the copay would be $750/month. Does that make sense?

[Alturia]

Your actual costs will depend on the specific Medicare Part D plan/insurance company you have. You can check the cost of drugs by logging onto your Medicare account and selecting Health Drug Plans. It is a really helpful tool.

I entered Erleada into the Medicare tool using my Part D plan - AARP MedicaresaveRX Plus - and it looks like the cost would be about $763 once you are out of the donut hole and into the catastrophic coverage phase - that's pretty close to what you estimated.

[Fightinghard]

investigate drug company and other foundations that might help.

many will cover most or all of the copay

[sillyoyster]

I am on Erleada. Jannsen Pharm will give you the drug for free based on the taxable income reported on your last filed 1040. My best guess is under 65K.

[Tommyj2 in reply to sillyoyster]

how old are you? Are you on Medicare? Most often these drug discounts are offered only to those on commercial insurance…I’ve never been able to discern why.

[Bethpage in reply to Tommyj2]

I've been told the Federal-Kickback Statute.

[Tommyj2 in reply to Bethpage]

don’t understand the response….sorry. Could you elaborate?

[Bethpage in reply to Tommyj2]

Sure, just Google the Federal-Kickback Statute. The federal government considers patient assistance to recipients of federally-funded insurance (Medicare) as remuneration (read inducement) for using one particular med over another. It's not fair, but it is the law. The entity that gave me this info was Novartis. This is an excerpt: "Anti-Kickback Statute [42 U.S.C. § 1320a-7b(b)]

The AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients). Remuneration includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. In some industries, it is acceptable to reward those who refer business to you. However, in the Federal health care programs, paying for referrals is a crime. The statute covers the payers of kickbacks-those who offer or pay remuneration- as well as the recipients of kickbacks-those who solicit or receive remuneration. Each party's intent is a key element of their liability under the AKS."

[Tommyj2 in reply to Bethpage]

thank you for the clarification….talk about a conundrum!

[Bethpage in reply to Tommyj2]

And such a hardship for those who typically no longer have the disposable income.

[Fightinghard in reply to Tommyj2]

many drug company offers are only for commercial ins covered patients

The foundations will help with those on medicare too yes they do have max taxable income limits but for most on SS qualification is not difficult

Look up

PAN - patient access network

TAF - the assistance fund

[Tommyj2 in reply to Fightinghard]

thanks for the response and info….

[sillyoyster in reply to Tommyj2]

I am 74 and on Medicare and blue shield. All that matters is your income level with Jannsen Pharm. Just go online and fill out the form. I pay $0 for Erleada.

[Tommyj2 in reply to sillyoyster]

I don’t need it yet but my time is coming….I have very low income so keep track of what others are paying for meds…..glad you were able to get the assistance.

[j-o-h-n]

Changed to cocreate-pay from co-pay...........

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 05/25/2023 7:17 PM DST

[hfl20]

In addition to PAN and TAF, try Healthwell Foundation and Patient Advocate Foundation Co-pay Relief (https:copays.org/).

After 1 month on Erleada you will pass through the donut hole (>$7050) and only be responsible for 5% of the medicare-approved amount on all prescriptions. I have traditional medicare and part D through Wellcare. After 5 months of taking Erleada (of my 24 months of ADT), the pharmacy at MDACC gave me a form to fill out that they completed and sent to Jannsen for a grant for Erleada for 12 months, so I'm covered for this year... Most of the grants allow funding (when available) providing your income is less than 500 to 800% of federal poverty level. I'm also taking Orgovyx which is Medicare approved at only $2709.18/month of which Medicare pays 80% and Wellcare pays 15% (after the initial deductables of $7050).

I haven't looked at the latest numbers, but last year:

chart

[Hidden]

Its Part B not D You'll only pay 33% of your providers negotiated price.

Eligard is monthly SubC injections.

Why not Lupron? It's the same ingredient. . You'll only pay 33% of your providers negotiated price.

For me its $366 per 6 month IM injection.