PSMA Scans?

[Dlanghorne]

I was told that insurance will only cover 3 PMSA/PET scans in a lifetime. Both Medicare and my supplemental insurance. Is that true??

[tango65]

No. Medicare part B pays based in medical necessity. I already had more than half a dozen of PSMA PET/Cts and Medicare always covered the cost.

If you have some Medicare Advantage, the insurance company managing your Medicare may limit the number.

[6357axbz in reply to tango65]

Medicare advantage plans are risky for very sick people like us. They also typically limit one’s ability to see a specialist unless specifically referred to by an advantage md.

[tango65 in reply to 6357axbz]

They pay using capitation which could lead to underpayment to the hospitals and medical groups.

Limiting the number of procedures and having large copayments for expensive medicines is the way that they can keep in business.

There are cancer centers which accept Medicare but they don't accept Medicare Advantage. The Sloan Kettering in NY is one of them.

With advantage plans one does not have control of one's Medicare. With straight Medicare you can see any doctor or go to any medical center anywhere in the USA which accept Medicare.

[mrscruffy in reply to tango65]

My Advantage plan is a PPO and i have used it everywhere. They have never refused to pay anything incurred at City of Hope. I picked my plan based on acceptance of this plan. A friend is a Medicare broker, he helped me wade through the plans and pick the best one

[tango65 in reply to mrscruffy]

Great. Most counties don't have Medicare Advantage PPOs.

[mrscruffy in reply to tango65]

Western AZ, nothing is "normal" here

[Cactus297 in reply to mrscruffy]

You are very fortunate!

[mrscruffy in reply to Cactus297]

Only problem ever encountered is going into the "donut hole" on drugs. Luckily I have a very generous pension so didnt hurt so bad. Spent my way out of it pretty quickly

[Cactus297 in reply to mrscruffy]

Have never hit the “donut hole” but once you’ve spent your way out of it I guess the prices of medecines I guess drop a lot. I’m so happy for you having a generous pension because not everyone has that!

[mrscruffy in reply to Cactus297]

Ya my dad was a CFO and taught me money management at an early age and showed me how to retire early. I am blessed. Strange thing is I tried to buy my way out of the hole which I think was 3K. They wouldn't let me so I had to buy the drugs for a high price until I was out. Seemed to drop back to pre donut hole prices

[Cactus297 in reply to mrscruffy]

From what I’ve read after you complete the donut hole the prices is drop again!

[mrscruffy in reply to Cactus297]

Yes they went back to the pre-donut hole prices

[JPnSD in reply to tango65]

But be careful...if you have had Medicare Advantage program for 24 months and try to switch to regular Medicare...and you have a serious diagnosis...NO ONE will sell you Medicare gap insurance (like AARP) for the 20% not covered by Medicare. You have to move out of the service region to start the 24 month clock again.

[Cactus297 in reply to JPnSD]

Good information!

[Teacherdude72 in reply to 6357axbz]

So far, 9 years, I have had no limits. Medicare advantage plans

[Cactus297 in reply to Teacherdude72]

That’s great you found such a good plan!

[Dlanghorne in reply to tango65]

I have had 2 scan 100% paid for. WhenI asked about when the next scan my oncologist said Medicare is now limiting to 3 total. He said it was new for 2024????

[fast_eddie in reply to Dlanghorne]

I hope that isn't so. I've already had two scans the last two years. I have Medicare supplemental Plan F. Did I see something to the effect that that particular flavor of Medicare plans is no longer available?

[Cactus297 in reply to fast_eddie]

I’m on a Supplement F too and hadn’t heard that. Hope it’s not true.

[6357axbz]

I’m told that my cancer center, MD Anderson, does not accept advantage plans.

[spencoid2]

Supplemental plans vary widely. I was lucky enough to marry a guy who had good insurance through the university of SF and they cover pretty much everything that medicare does not. Why don't they change the names to disadvantage plan which is more appropriate.

[carbide in reply to spencoid2]

You are lucky. Healthcare in the United States is like gambling, like going to a casino. If you're lucky you win if you're not lucky you die. All about the money!

[Concerned-wife]

I can’t find that rule for USA Medicare. It looks like that might be true for Australian Medicare.

You can go to CMS.gov to find coverage info…easier if you have a code. I am finding some policies retired last year.

[GoLowPSA]

I have read the same thing for Medicare starting in 2024 and going forward- 2 scans in a lifetime:

apexradiology.com.au/new-me...

[Still_in_shock in reply to GoLowPSA]

Australia

[j-o-h-n]

"Hello I'm calling to find out if your medical facility takes the Medicare Advantage Plan?". You do, that's great, and to answer your question about me being a citizen. I am a citizen." CLICK........ hmmmmm dial tone......hmmmmmm

Good Luck, Good Health and Good Humor.

j-o-h-n