Medicare coverage

[gymbunny1]

Those of you on Medicare does it cover your prescription foe calequence? My boyfriend is about to go on Medicare and the agent said it will only pay for intervienance chemo.It was very upsetting to hear

[Shepherd777]

If you look to the right of your posting you will notice Medicare and Calquence/Acalabrutinib responses. There are a number of financial helps available.

[lankisterguy Volunteer]

Hi gymbunny1

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Medicare is very complex and you may want to see this Patient Power article.

patientpower.info/navigatin...

Then you can get expert help here:

medicare.gov/basics/get-sta...

shiphelp.org/local-medicare...

Be very careful about accepting help or advice from insurance agents and websites that do NOT end in ".gov" , as there are many people trying to sell Medicare Advantage Plans that would not be wise for most CLL patients.

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The basic Medicare (Parts A & B) don't cover prescription drugs taken at home, your boyfriend will need to purchase a Part D plan here:

medicare.gov/drug-coverage-...

medicare.gov/drug-coverage-...

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Part A: These policies cover inpatient care at hospitals, as well as care delivered via hospice, home health, nursing home, and skilled nursing facilities. Most people who worked at least 40 quarters in the U.S. don’t pay any premiums to participate in Part A, and the 2022 deductible is $1,556 per benefit period.

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Part B: These programs cover office-based (non-hospital) visits and care. The standard monthly cost of a Part B policy is currently $170.10, although some people with higher income pay more. The annual deductible for Part B is $233, after which you pay 20 percent of your doctor visit costs.

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Part D: These policies cover prescription medications. Like Part C, you can create a plan that fits your needs, which will dictate your premiums and out-of-pocket costs.

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Medigap: Also called Medicare Supplement Insurance, private companies sell policies that cover the costs that Medicare policies don’t. These are available to people with both Medicare Part A and Part B, and the costs and out-of-pocket charges will vary based on the plan you need.

[wizzard166]

Hey Gymbunny

Medicare is my work, so it's easy for me to answer your question accurately.

Yes the various Part D Rx plans will cover Calquence. The first Month will be a huge bummer with a cost of about $3315 on almost any plan. Then after the first Month you will pay $795.88 per month.

There are four stages of cost in Medicare Part D Rx coverage.

First Stage is Deductible. Most plans have $505, some $350 and a few $0. The ones that have a $0 Deductible however cost somewhere between $80/month and $120/month. The other plans vary between around $15/month and $40/month, with most having the $505 annual deductible. With a drug that will cost as much as Calquence however, it really doesn't help to have the more expensive plans.

Second Stage is Initial Coverage, which starts after the Deductible. In this stage you usually have a copay or a percentage, but the actual retail cost of the drug will ultimately lead you into the third stage right away

Third Stage is the GAP. In the GAP you pay 25% if actual retail cost. You get into the GAP when actual retail cost added up monthly reaches $4,660 in 2023. But again you will be in and out of the GAP in the first month anyway.

Fourth Stage is Catestrophic. You reach Catestrophic when total actual retail cost hits $7400. In Catestrophic you pay 5% of Cost. Again a drug like Calquence costs $14,602 per Month. So you end up in Catestrophic in the first month too.

Since the actual retail cost of Calquence is $14,602, the 5% Catestrophic Monthly cost will be $795.88. The first Month is more because you don't get to the 5% Catestrophic until you were forced to pay the Annual Deductible, Initial Cost, and GAP Cost also in that first Month.

Carl

[Teemed]

can you use a HSA ( health savings account) with Medicare part D?

[skipro]

Hi

I went with social security medicare because it does NOT limit options like a cheaper Medicare Advantage. MCR covers 80% or all infusions with a low deductible and no copay if you get a supplement or MCR part G.

You need a Medicare D or drug plan to cover oral meds. It's still expensive, around $10K per year for things like Ven, and BTKi's.

You can log onto MCR.gov and search under supplemental part D. You enter all your meds and it will show you the total cost of premium plus med in the various plans. You can also find a supplement that way as well.

Good luck, its a lot to sort out.

skipro

[gymbunny1]

Thank you to everyone for all the replies

[lisakc1 in reply to gymbunny1]

We found this out the hard way... choose VERY carefully as changes to part D plans can only be made during Open Enrollment in October which takes place the following January, so you are "stuck"for a year. These medications are essential and still so very, very expensive!

[OSUfan]

Calquence just raised monthly cost to $825 per month under Medicare Part D coverage. I get that drug from Cleveland Clinic Specialty pharmacy. That is for the new tablet.

[SofiaDeo]

Please know that the various drug companies offers free medication to certain patients directly. This is not run through the Medicare insurance system, although in order for them to agree to pay, the doctor first submits information to ones insurance and gets a "prior authorization". I have Medicare and got my Venclexta for free, mailed directly from the pharmacy the drug company contracts with. And when you look at my Medicare insurance records online, you can find the Prior Authorization but according to Medicare, no drug was ever filled through Medicare. So investigate the drug website, there will will be a link for Patient Assistance or something like that, to see if he qualifies.

[gymbunny1 in reply to SofiaDeo]

Thank you