Does Medicare part B and D cover all the major PC drug treatments with a minimal co-pay and minimal approvals i.e.Taxotere, Erleada, Xtandi, Pluvicto (Lu177), Dapolutamide, AC 225 etc. Also are PSMA scans covered?Thanks for your help.
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Lefty26
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They are only covered if they are FDA-approved for that indication. FDA-approved pills are covered under Part D, if your plan covers it. FDA-approved injections or infusions are covered under Part B. Experimental drugs and unapproved indications are fully covered if you are accepted into a clinical trial for it.
Only problem I have had with Medicare is I found myself in the dreaded donut hole in 6 months.
in reply to mrscruffy
With Xtandi, you flyover the donut hole into catastrophic for the second month!!
mrscruffy in reply to
Glad I am not on that one. what I don't like is I can't buy my way out of it. I can buy myself out of most everything hahaha
dhccpa in reply to
Never gone that far yet! Is there a max out of pocket for Xtandi on your Part D? Thanks!
shueswim in reply to
Keep in mind that under the Inflation Reduction Act passed last year, that the 5% catastrophic "goes away" in 2024 which effectively caps our out of pocket on a Part D drug plan at about $3k/year. Then in 2025 a hard cap of $2k/year goes into effect. No doubt the drug plan premiums will rise but nevertheless this will mean significant savings for those of us taking Xtandi.
Refer to Tall_Allen (above)...
Good Luck, Good Health and Good Humor.
j-o-h-n Tuesday 08/29/2023 5:35 PM DST
If you go on abiraterone (maybe others too) your part D copay could be thousands of $ per month. But bypassing insurance for GoodRX cam save the day.
Abiraterone is a generic so where the pharmacy buys their supply affects the price. I pay $168 for a 90 day supply of abieraterone under my Part D insurance.. That's $56 a month.
That would be nice! With my Part D plan (Wellcare I think) the $8,000/month cost of Abi dropped to "only" a 25% copay, or $2,000/mo. I get it through GoodRX for $187. This is at Rite Aid.
The problem is probably with the pharmacy and not your Part D insurance company. I use a specialty pharmacy that is part of the cancer center I go to. They buy the abiraterone from Celltrion USA. And Celltrion USA imports it from Qilu Pharmaceuticals in China. The pharmacist I deal with told me that if they sourced abiraterone from the same company that CVS. Walgreens, etc. then my cost would be about $1500 a month.I wonder if your cost of $187 through GoodRX uses Celltrion/Qilu?
Prices are wildly different on all these drugs depending on the carrier….your insurer is the cheapest that I have ever heard for abiraterone……could you tell us who that is?
AARP Medicare R administered by UnitedHealth. But I really think the key to the low cost is the pharmacy supplier Celltrion/Qilu. The pharmacy said if they used any of the other suppliers the costs would have been significantly higher. So the only difference is the wholesale supplier not the insurance.
so you are in a Medicare advantage plan?
No I am in original Medicare and it is a Part D drug plan.
Sorry…got confused with the Medicare R….glad it’s working out for you…..what state?
Rhode Island
Too bad…if it was NY I would have switched….I’ll check prices with the AARP drug plans this season.
If you use the Medicare tool to compare Part D costs for aberaterone you get inflated costs. I don't know where Medicare gets it's costs for aberaterone but it is a lot higher than what Celltrion/Qilu costs. I picked the least expensive Part D plan based on the costs Medicare lists.
Unless there is a way to buy directly from Celltrion(a Korean company relatively new to the biopharmaceu tical industry) I’m pretty much left with the Medicare search tool…. I’m imagining that the pharmacy managers for United Healthcare use similar outlets so I would search the United Healthcare related part d plans first.
I’ve found that Medicare cost tool to be somewhat unreliable. It even states somewhere in the fine print that the actual cost could change depending on where the Part D plan gets its drugs. E.g., If they’ve been getting it from a factory in India that gets ‘shut down’ by the FDA then the plan has to find a different source for the drug and the contract with the new supplier might not be at the same price as was negotiated with the earlier source.
Lefty can you please "right" info regarding your bio. It helps you and helps us too. Thanks..
Good Luck, Good Health and Good Humor.
j-o-h-n Tuesday 08/29/2023 10:11 PM DST
Every drug is different and every Part D carrier is different you will need to do more research. I believe (original) Medicare will cover the PSMA scan, they have no say in your medical treatment as long as your physician deems it necessary the have to cover it. Unless you have a Medicare Advantage plan, that is a whole different situation.
Many of the drug companies have programs for financial aid assistance, again they all vary so you need to research further.
Also there are changes coming to Medicare Part D in 2024 and 2025 to assist with the more expensive medications.
There are medical necessity restrictions in non Medicare Advantage plans too.
absolutely not true; original Medicare CANNOT deny any procedures deemed necessary by your physician
in reply to SilverSeppi
Medicare advantage plans must provide everything Medicare would pay for.
SilverSeppi in reply to
Absolutely not. Medicare advantage plans are like an insurance carrier; they have the right to deny treatments based on their own factors; original Medicare has NO such restrictions.
in reply to SilverSeppi
medicare.gov/sites/default/...
What do Medicare Advantage Plans cover?
Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.
Most Medicare Advantage Plans include Medicare prescription drug coverage
(Part D). In addition to your Part B premium, you usually pay one monthly premium for the plan’s medical and prescription drug coverage.
Plan benefits can change from year to year. Make sure you understand how a plan works before you join.
SilverSeppi in reply to
not quite
cmadocs.org/newsroom/news/v...
kff.org/medicare/press-rele...
crr.bc.edu/advantage-plans-...
in reply to SilverSeppi
Mine has no pre authorizations to meet.
My MO says I'll send a referral for a PSMA/PET, Nuclear Radiology dept is calling me as Im leaving in the parking lot.
I ask my PCP to see an Endocrinologist, my phone rings before we are done, I see caller ID as Kaiser, oh, its the Endo dept calling to make an appointment!!
NEVER have I been denied treatment, never have I waited for an authorization.
I did my homework after my wife's Anthem BC was denying everything, which was illegal.
Shams_Vjean in reply to
But try going outside of the Kaiser network to somewhere like City of Hope or MD Anderson and watch what happens!
Also, “Plan benefits can change from year to year.”
Some do great inside of an Advantage plan’s network and others not so much. Glad it works great for you.
in reply to Shams_Vjean
Why would I need to go there?
Kaiser Los Angeles is a Cancer Center of Excellence
Shams_Vjean in reply to
Not saying You need to; but not everyone lives in a locale where the Advantage plan’s network includes a cancer center of excellence, so 2nd opinions from outside the plan’s network can be game changer for some.
in reply to Shams_Vjean
2nd opinions outside Kaiser are paid for and encouraged!
Go to medicare.gov where they have a useful search tool for you to find each drug's cost with different plans. So you can find the least costliest plan.
Many on this site including me feel it is better, if you can afford it, to purchase a supplement and drug plan rather than a Medicare Advantage plan. For example, if you want to travel to a special center for care such as Mayo or MD Anderson.
Be careful about choosing your supplement. It is medically underwritten and hard to switch later your drug plan can be switched annually You can go to Medicare.gov and estimate your costs of your drugs under various plans in your area
ALL supplement plans, by law, must provide the same coverage. The costs vary but for example Plan G is the same between any of them, by law. You can switch Plan D drug plans during the open enrollment period without medical underwriting needed (not so with the supplement plans).
Adding a few points to what’s already been said…(1) make sure you’re on a Medicare Supplement plan, not Advantage, (2) for “specialty” drugs like Nubeqa, you’ll be paying at a much higher, Tier 5, level, (3) for the Tier 5 drugs, check with the drug company about financial support, they can provide 100% coverage if your income (not assets) is less than $90k, 300% (I think) of federal poverty level. Otherwise, Medicare has been great and all my treatments have been covered 100%. Good luck!
Good question.
I have Medicare and USAA as a supplemental. If Medicare approves a medication or treatment USAA picks up the amount that exceeds Medicare cap. My Lupron injections are fully covered. (Abiraterone) Zytiga is not covered. Fortunately my Oncologists Pharmacist found a Grant that covers my Zytiga.
Aside from Tall Allen’s very thorough explanation, most who use traditional Medicare plans, not Advantage plans, find that the major out of pocket expenses come from the orally administered drugs covered under Part D.
Of the various meds of that type approved by the FDA for treating advanced Prostate Cancer, Zytiga is the only one available as a generic, Abiraterone Acetate. The List price for all the others are quite high, and the patient assistance programs offered by the drug manufacturers often exclude those of us covered by Medicare.
My Oncologist set me up with a mail order pharmacy that arranged for me to get financial assistance via a charitable foundation. It’s also possible to go directly to many of the charitable foundations which offer financial assistance for PCa patients, if your Part D copay is high and your income meets the foundation’s criteria for assistance.
Best of luck!
So my Xtandi is $97 monthly with company insurance.
I plan to retire in 2 months my understanding is Medicare D plays 80% of cost which is $15,000 per month and I play remaining 20% which is $3000 per month . How am I supposed to afford?
See the 3rd reply in this thread. And check into the manufacturer’s and private foundation financial assistance programs NOW.
Ask your Oncologist if they if they have a navigator on staff who can help you with that or if they work with any mail order pharmacies that can help patients arrange for foundation assistance.
Also, thanks to the Inflation Reduction Act program taking effect in 2024 & 2025 your out of pocket drug costs via Part D will be capped at either $3 or 4k per year in 2024 and at $2k per year in 2025 and beyond. I’d tell you who to thank for that, but it’s sometimes not appreciated, even though true.
Thanks for the info. Has "the Inflation Reduction Act program taking effect in 2024 & 2025 your out of pocket drug costs via Part D will be capped at either $3 or 4k per year in 2024 and at $2k per year in 2025 and beyond. " passed into law?
Yes, it was part of the first major piece of legislation passed by proposal of the current administration. But there’s no guarantee some future legislature or administration might not try to ‘gut’ or repeal it down the road.
Also I believe the cap is supposed to be indexed to inflation after 2025. E.g., If you see a 3% increase to Social Security benefits in 2026 then the out of pocket Plan D cap would be 3% higher, i.e., go from $2,000 to $2,060.
in reply to diatom
I believe Part D plans you pay 33% of tier 5 drugs
That’s from comparing plans on medicares website.
If you’re 2 months away you can already shop at Medicare website.
My oncologist recommended mark cuban cost plus drugs. 120 tablets, 250 mg cost 132 delivered to my door.
I looked on the site but did not see Xtandi listed
No , you won’t because Xtandi is not available in generic until 2027. My oncologist told me I could probably get it free based on my income. I went with Zytiga because that is usually tried before Xtandi.
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Good Luck, Good Health and Good Humor.
j-o-h-n Thursday 08/31/2023 5:15 PM DST
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