Orgovyx costs with Medicare Part D

[maley2711]

In considering Orgovyx, I came across this calculator for drug costs when using Medicare Plan D....

q1medicare.com/PartD-PartDC...

Using $2600 for Orgovyx monthly costs, the calculators for 2023 and 2024 indicate 12 months of Orgovyx in 2023 would be $4100 out of pocket, and in 2024 the out of pocket would be $3100.

Can anyone confirm that this will be your actual out-of-pocket for 12 months of Orgovyx in 2023?

If this calculator's result doesn't align with your actual experience, do you see an error in the computation done by the calculator?

I am asking because I have been under the impression that Orgovyx would cost Medicare D beneficiaries substantially more than these results are indicating?

[cesanon]

I think you need to look at who is your part D insurer as well?

Some might not even cover it.

Though perhaps you are just looking for a worst case analysis?

[Hidden in reply to cesanon]

If its in the Medicare Formulary, then Part D insurers need to cover it.

[cesanon in reply to Hidden]

It would appear each private Medicare insurer has their own plan. My recollection is that they can change it midyear or any time they want.

Somewhere on the Medicare site is a way to compare drug coverages between the various plans.

2024 Medicare formulary (drug list)

Https://healthpartners.com/insuranc....

"What is a formulary (drug list)?

Each Medicare prescription drug plan has its own list of covered drugs, known as a formulary."

[DrawingSnowmen]

For 2024 there's a maximum cap on out of pocket Medicare Part D drug costs so that would account for the difference between 2023 and 2024.

[Hidden]

Thats about right. The cost of the first month blows you past the donut hole directly into catastrophic. Your max out of pocket is already used up in the first month.

[Concerned-wife]

medicare.gov/ is the official government site and it appears to be set up now to check drug prices under the new 2024 rules.

You can change your Part d plan each year during open enrollment, which is soon.

Always a good idea to input all your drugs and see which plan has the best annual cost for you.

[Concerned-wife]

I was just reading an excellent NY Times article which stated “Changes in the Part D program under the Inflation Reduction Act will effectively act as an out-of-pocket cap of $3,300 next year, KFF estimates. Dr. Neuman said it was “a big deal that hasn’t gotten a lot of attention.”

I quickly checked the Medicare.gov site and this was the amount it showed. Wow! Great news!

[85745]

My doc made a quick mention medicare is not a big fan on Orgo, then said they had patients that stop taking it as prescribed or forget to take. Plus it is a special pharmacy drug that requires a nurse / user follow up monthly. and special delivery. I myself backed away from all the cut-burn-poison for now , staying on course with the Fenben/ Ivermectin, and herbs like Pao Pereiro a powerfull anticancer herb along with liposomal Baicalein, Betulinic acid. Just to name a few. Oh, and no neg side effects. Everyone has to travel down their own path( or follow doctor orders) this is my choice , I can tell you my conventional doctors don't like it or me, lol. If I was to have radiation or chemo, even go on adt you can bet I would be taking Zeolite and Tudca. My best caregiver and healer is by faith and my prayers . Fear not for I am with you Isaiah 41:10.

[maley2711 in reply to 85745]

good luck !! I don't believe folks are " following Dr. orders "...they are accepting professional advice. Folks who prefer to follow treatments whose efficacy has been proven in well done studies . Yes potential side effects suck and must be considered when deciding

[Explorer08]

I pay $72.30 per month copay for Orgovyx. My insurance is United Healthcare Medicare Advantage PPO with OptumRX as the prescription drug insurer. I just learned that the cost will remain the same in 2024.

[maley2711 in reply to Explorer08]

wow, that is amazing !! That is way less than what Part D rules allow for D plans. You don't have that thru a retiree medical plan do you? That is, did you purchase the D plan thru an insurance broker, or thru employer plan, or directly from insurer. Interesting you have one of those often reviled PPO plans . Have you had any gripes about it....obviously Not for that drug coverage!!

[Explorer08 in reply to maley2711]

Yes, it is a retiree medical plan. Incredibly lucky to have it. No copays for doctor visits. Small copays for ER visit and in-patient hospital stays. Zero complaints.

[maley2711 in reply to Explorer08]

So, your old emplyer is paying the difference between what I would pay and what you are paying......lucky you, sincerely!! Stil. I'm pleasantly surprised even with $3-$4k out of pocket, and lucky I could afford even that. I 1st thought it would be more like $10k for a year, and no way at that price !! Just grin and bear those damn shots..and I've had some undiagnosed physical situations(fainting?) that o tests/scans have resolved, but heart problem definitelt a possibility....and foranyone age 75!! So another reson for Orgovys......or at least the free Firmagon shots(monthly....ugh?). Wonder if oncologist here would be positive about Orgovyx instead of Lupron or Eligard??

[Explorer08]

My oncologist, in partnership with my cardiologist, had to make three attempts to get Orgovyx approved. It worked on the third try, thankfully. Cardiac issues, both current and potential, were what convinced insurance to cover it. That seems to be the key to getting insurance coverage - lower risk of cardiac issues with Orgovyx.

[maley2711 in reply to Explorer08]

So , in this case, the insurer is Optum RX, and not Medicare...though it is to a great extent funded by Medicare!!!?? Is it in the formulary document provided by OptomRX? Does it note only special situations for approval? I'm still trying to get a handle on how all this works re approvals, etc!!

One other thing..... I see you are challenged now by gynecomastia, and attribute that problem to Orgovyx. Is gynecomastia more of a possible problem with Orgovyx than with Firmagon, Lupron, Eligard, etc......or a problem that is actually an outcome from any ADT protocol, including surgical removal? Some men mention the problem , and some don't...seems often I see radiation suggested?

[Explorer08 in reply to maley2711]

OptumRx is my Medicare Part D plan that goes along with the Medicare A & B components, all three managed by United Healthcare which is paid by our retiree health plan provider to manage. That "management" is performed under the contract United signs with the retiree health plan and is NOT the standard United Healthcare plan one might purchase directly from United. If any given drug is FDA approved and approved by traditional Medicare then OptumRx has to provide it - - however, some drugs are top tier drugs coming from their specialty pharmacy division and often require substantiation from the doctor. Orgovyx is one of these drugs (as is Xtandi). Zytiga, on the other hand, has gone generic and is just approved automatically (and costs $15 per month copay). And, yes, Orgovyx is in the OptumRx formulary (so is Xtandi).

Gynecomastia, as I undestand it, is not caused directly by the ADT drugs but, rather, by the loss of testosterone. Like anything else there is a spectrum of reactions to the ADT drugs - - some men have terrible gynecomastia, some men have mild, and some others have none at all. Too many variables for me to understand the scientific complexities.

[maley2711 in reply to Explorer08]

Thanks........so another thing to remember and ask about before choosing which D plan...even if something is in the formulary, does the D insurer require a special request from a provider!! can they complicate our insurance coverage anymore????