Questions about ADT drugs and insurance

[SilverSeppi]

Will Medicare cover Lupron injections under part B as it is not self administered (as opposed to pills)? If so how much will they cover (with a supplement plan).

Regarding Orgovyx, since it is a pill and not an injection will it be covered under Medicare part D drug coverage? and if so do all of the plans under Part D cover it or only some? The retail cost is over $2000 for a 30 day supply.

As for Casodex, I believe it is a relatively inexpensive/generic drug and thus much cheaper also only given at the beginning of hormone treatment...correct?

Thank you!

Joe

[Tall_Allen]

Yes Lupron is covered by Part B. It covers 80%. If you have a Medigap/Supplemental Plan, it covers the remaining 20%.

Orgovyx may be covered by Part D -check your plan.

Bicalutamide is always covered by Part D, and is only given for a couple of weeks.

[Hidden in reply to Tall_Allen]

The rule is:

If a nurse or doctor supplies the meds, and holds the syringe it's part B (20%)

If you pick up the meds at the pharmacy, and you hold the syringe, it's part D (copay)

[Hidden in reply to Tall_Allen]

Just received my 6 month Lupron, an hour ago.

My Kaiser Medicare copay was $366.00😂

[Tall_Allen in reply to Hidden]

Is that an Advantage Plan?

[Hidden in reply to Tall_Allen]

Correct

[Tall_Allen in reply to Hidden]

Unfortunately, once one is trapped in an Advantage Plan, it's difficult to get out of it into a Medigap Plan. My friend is trying, but it looks like he would be responsible the 20% costs for pre-existing diagnoses for 1 year.

[Hidden in reply to Tall_Allen]

In my case that would be 20% off all medical treatments!!!

[pakb in reply to Tall_Allen]

My husband and I are 55- so no Medicare yet (we use ACA as we are both self employed) but I hear staying away from advantage plans is best.

[Woodstock82 in reply to pakb]

Metastatic prostate cancer allowed me to apply for SSDI under the compassionate allowances program. I was 57 at the time. I applied online, and then mailed in the supporting documentation. I was approved. That started a 30-month clock, after which coverage by Medicare Part A and Part B goes into effect.

In hindsight, I should have done it sooner after diagnosis, instead of waiting.

[Foldem in reply to Tall_Allen]

I have a Kaiser advantage plan and have never paid for Lupron. Xtandi was expensive because of the donut hole in Medicare coverage.

[RayF in reply to Hidden]

On my plan I pay nothing for Lupron, and $100/month for generic Zytiga. When I was with Kaiser pre-medicare, Zytiga was $360/month.

[HikerWife in reply to RayF]

Ray, check out Mark Cuban's Cost Plus drug company - we are paying around $40 (inc. shipping) for generic zytiga. costplusdrugs.com/

[Tommyj2 in reply to HikerWife]

That price appears to be for 30…will need 4x that amount monthly……still a good price.

[HikerWife in reply to Tommyj2]

Oops, yup. Eric is on the 250mg/day plus lowfat breakfast regimen. Food increases uptake & no need to take on an empty stomach.

[Tommyj2 in reply to HikerWife]

Is this regimen working for him? When my time comes I’d much rather take one pill daily than 4….both monetarily and remembering to dose 4x daily.

[HikerWife in reply to Tommyj2]

Yes, he's had a great response to it. We have a local MO and a prostate cancer specialist MO at Dana Farber, and they are both on board with the protocol. Basically you take one 250mg pill along with a meal (breakfast) that is roughly 300 calories and less than 10g of fat. He's not into eggs at all, so has been eating things like an open face turkey or chicken sandwich with a packet of mayo, or Cuban black beans and rice, or chicken/veg soup with barley, an Indian-spiced chickpea stew with rice, or an english muffin toasted, with a slice of cheese (70-80 cal) and canadian bacon (to add up to 300 cal), and melt it all in microwave. It's a lot of adding up & tweaking of calories and fat to start, but doable.

[Tommyj2 in reply to HikerWife]

Great to hear….thank you for the detail.

[Hidden in reply to RayF]

It all washes out.

I have a $999 max out of pocket

No copays at all except for $50 CT and PET Scans

Pharmacy:

I pay $3 for generic Zytiga!!

Most prescriptions have no copay. Also no deductible.

[Bret5]

I’m in middle of signing up for Medicare effective Nov 1 so I researched all this. What another post says is true, it is part B if injected or infused at hospital or doctor office. I’m going with supplement plan G so costs from hospital or doctor office will be almost nothing after small part B deductible.

Keep in mind the law changes next year and again the year after for out of pocket exposure on part D. I already will be hitting the max with my nubeqa so for example I might switch from Eligard injections to Orgovyx pills. The $$ exposure will probably be nothing.

I don’t think a lot of people realized that the inflation reduction act which was politically controversial will save people like us 6 to 8 thousand dollars a year depending on your meds.

Note that current websites like Medicare.gov only show this year costs. Those are grossly overstated for next year. But the brokers and providers don’t have the next year detail yet.

Last, keep in mind that all these tier 5 specialty drugs require pre approval from your insurer. Often they want to push you to a lower cost alternative. But from what I’ve learned, this is not as bad an issue with Medicare as it is with private insurance.

[Concerned-wife in reply to Bret5]

Excellent summary. I usually advise people to go to Medicare.gov and compare plans for their area but hadn’t thought about the change next year not being reflected there yet

[Tommyj2 in reply to Bret5]

What is the change next year? My understanding was that it doesn’t take effect until 2025.

[Bret5 in reply to Tommyj2]

It’s a graduated implementation. For 2024 the out of pocket will roughly be capped at $3500 then for 2025 and beyond it will be closer to $2000. If you google this you will find a number of articles although the specifics are not out there yet. Here is a pretty good explanation:

kff.org/medicare/issue-brie...

[Tommyj2 in reply to Bret5]

Thank you so much for this info…..very heartening.

[Bret5 in reply to Tommyj2]

yes, those are big $$. Our ability to afford should never be a barrier to the best care and best drugs.

[FRTHBST]

Well, unfortunately Medicare Advantage is an attempt to slowly privatize what we've known as Medicare. Advantage was initiated under GW Bush in the early 2000's and basically is a private insurance company administered plan. One's notion of whether it is a good or bad idea to supplant the original government Medicare with a partially private plan seems to be at least related to political leanings. With original Medicare and a Medigap plan G(already partially privatized, though heavily regulated on what insurers may or may not do) I have had no questions about hospitalizations, medications(currently on Orgovyx) or additional bills. My income is low and I also receive "extra help", a plan administered by most states that pays for part of my premiums(this is well worth checking out when you make your decision on whether to take regular Medicare or an Advantage plan.) My feeling is that regular Medicare with medigap G will always be better if one is already sick with a chronic illness because of the lack of need for pre authorization for most procedures, not having any restriction as to networks, and no additional out of pocket for hospitalizations(again I do have the "extra help" provision).

[Explorer08]

I have United Healthcare Medicare Advantage. My Orgovyx prescription costs me $72.30 per month copay. It is mailed to me through their OptumRX home delivery unit. We have zero copays for everything else. It is astonishing how highly variable coverage is.

[j-o-h-n]

I joined the kids out there and steal my drugs.... I even get a goodbye handshake from the drugstore manager as I leave.............

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 08/08/2023 5:56 PM DST