Does traditional Medicare pay for PSMA scans and Lu-177 (pluvicto) treatments?

[Lefty26]

Have private insurance thinking of changing over to traditional Medicare (with Medigap supplement)...any disadvantages?

[Tall_Allen]

It pays only if FDA-approved qualifications are met. For example, PSMA PET is only approved if (1) HIGH-RISK, (2) Recurrent, or (3) To qualify for Pluvicto treatment. Pluvicto is only FDA-approved and Medicare-covered in men who are metastatic and castration-resistant and PSMA-avid and have had chemo, failed either Xtandi or Zytiga. Medicare w/ Medigap + drug plan provides a level of flexibility you can't get with a Medicare Advantage plan.

[Mjex in reply to Tall_Allen]

Is there anyway to switch to a Medigap plan after you have been enrolled in an Advantage plan? I tried a few years ago and was met with "pre-existing" condition rejection.

[TMcgee in reply to Mjex]

I just asked the same question to a Medicare Insurer and was told that the insurer cannot ask medical questions within 30 days of applicant’s birthday or 30 days after. I believe that the state regulates your eligibility, so I suggest following up with your state.

[Tall_Allen in reply to Mjex]

I have a close friend who is trying to do that, and it has been a nightmare for him. He wanted specific doctors. What he was able to do was switch from a United Healthcare Medicare Advantage HMO Plan to a United Healthcare Medicare Advantage PPO Plan. They agreed to the switch but he will incur a maximum out-of-pocket of $7500/year, which he can afford. Eventually, United may agree to sell him a Medigap Plan, but for at least a year, they will not cover pre-existing conditions, so he would be responsible for 20% of doctor and hospitalization costs attributable to his prostate cancer for at least a year.

[Mjex in reply to Tall_Allen]

Thanks. I am going to try to make the switch. I was looking at some of the regulations that let you "start over" like a change of state or the provider goes out of business." If I figure out a way to switch to Medigap, I will post the results. And let me again thank you for all of the cogent advice you have provided the group.

[Tall_Allen in reply to Mjex]

I know some states allow switching in the first year around your birthday. You can go back to Part A&B also if you go into a nursing home for 1 day, but that only covers 80%. Good luck, and let us know how you do it.

[tango65]

Traditional Medicare pays based in medical necessity . I had Pluvicto and I never had chemo. They paid for each treatment and by the Spect studies and PSMA PET/CTs studies to evaluate efficacy of the treatment.

[Lefty26 in reply to tango65]

Thank you

[Flyfisherbug in reply to tango65]

Was that part of a trial?

[tango65 in reply to Flyfisherbug]

No

[Lefty26 in reply to tango65]

Was Pluvicto covered under your part B or part D? I presume your PSMA Pet was covered under part B? Is Chemo covered under part B?...What is your drug out of pocket?

I'm asking all these questions because I'm on my wife's private insurance at the moment and can choose to stay or switch to Medicare. I thought I should change to medicare because MD's love the fact no approvals are necessary with Medicare and I thought the maximum drug out of pocket is $3000+ in 2024 and $2000 in2025..but I just heard from an insurance agent that is not really true in2024 will be more? And that premiums will be hugely raised for part D in 2025.

[Lefty26 in reply to Lefty26]

I'm on erleada evey month at no cost and lupron $ 400 every 3 months

[Lionsbuddy in reply to Lefty26]

I think Lupron is supposed to be covered under Medicare Part B if injections occur at the Dr's office.

[Concerned-wife]

You need a drug plan, too. Medicare.gov has good tools to help you select plans. You can switch drug plans annually but it is hard to switch supplement plans because they are medically underwritten.

[Skifanatic]

Make sure you go to a Medicare supplement, not Advantage. If you start with Advantage you can never switch to supplement; if you choose supplement, you can always switch to Advantage (although you won’t want to, considering the flexibility you need to deal with PCa).

[Explorer08]

I have United Health Medicare Advantage PPO and it paid for my PSMA pet scan in total. No copay.

[VCinTx in reply to Explorer08]

Also with United Health Medicare Advantage PPO and it paid for my PSMA with a small co-pay.

[Miccoman]

I have always had traditional Medicare + Supplemental (Medigap). I have never had to pay anything for any medical procedures done in an office or hospital. That $233 a month premium has been well worth it!

Drug plans vary and Medicare.gov does a pretty good job comparing plans. The other big plus is that there is never a pre-approval required so no haggling with some insurance agent to get the care you want/need.

[Cancer2x]

Medicare just fully covered the cost of a PSMA scan for me (recurrent, PSA rising). Told they will cover two PSMA scans per year, more if your Oncologists fights as ‘medically necessary’.

I am just entering a Phase 1 Clinical Trial using MRI-guided “Adaptive” SBRT to lymph nodes and abdominal wall. Medicare has approved payment for this trial as well.

“SMART” Trial:

Stereotactic Magnetic Resonance Guided Adaptive Radiation Therapy

Basically the MRI is running while the radiation is being delivered, and allows the team delivery field adjustments based on any inter-abdominal movements caused by breathing, bladder filling, etc. to get optimal accuracy to the tumor/cells,nodes. Minimizes collateral damage to other structures (bladder wall, ureter, urethra, abdominal wall, rectum, etc.

Hope it is successful in squashing the cancer for a looong time!

Anyway, Medicare has been okay so far!

Good luck!