medicare

[Txsgrl]

Hi y’all I am still in weight and watch but I am curious if Medicare with a supplement pays for most of the drugs that people are using with this cancer thank you for your help. I appreciate it..

[larrymarion]

In 2025 new law places a $2k cap on Medicare beneficiaries' out of pocket for Rx drugs. In 2024 another provision will limit out of pocket costs to between $3-4k. Very complicated explanation for next year. Last summer LLS posted a webinar on the new Medicare rules.

[Tangolover]

The plan President Biden put in place for Medicare cut my prescription costs in half. Very nice!

[gardener58]

I've been on Brukinsa since September 14, 2023 and am paying nothing for the med. My provider is affiliated with a hospital pharmacy and they handle submitting requests for grants from the Healthwell Foundation, an organization that helps with copays.

My hem-onc informed me that the foundation is likely supported by the pharmaceutical companies to avoid bad publicity. If someone dies because of the cost of a drug, the negative press would be enormous.

He told me no one in the states should worry about paying for their needed meds.

Stay strong.

Andrew

[wizzard166]

Hey Texas Girl

My work is Medicare so I can answer your questions precisely.

With respect to drugs and treatment, in all likelihood you are referring to the "Pill? By the Pill I mean the BTK Inhibitors, the first of which that was FDA approved is Imbrutinib. Since then other BTK Inhibitors are being used individually and in combination. I'll soon start on Zanubrutinib.

Medicare Part D Rx covers these Pills. The expense is quite high. Specifically on most of the pills being used today the first month will cost close to $3000. This is because the typical retail cost of most of these medications is around $12,000 per Month. That is not what the Medicare Member on Part D pays, but it is the Retail Cost. We pay the Deductible on the plan, which today is around $505 and next year $545. We then pay the Initial Co Pay which isn't too great, but then we go into THE GAP (Used to be called the DONUT HOLE). In the GAP we pay 25% of Cost, which could be depending on the specific medication around $3,000 all by itself. All this happens in the first Month. Then still in the first Month we reach the Catestrophic Stage, and in Catestrophic Stage we pay 5%. It depends on which specific medication or BTK Inhibitor you take, but it seems on the average to be around $3,000 that first month. Then Catestrophic Stage for each other Month of the year might be around $700.

If a person qualifies for Medicaid in their State, then the out of pocket of course will be very little. There is a chart that shows for both Single individuals and Couples, what the income requirement is and also the Asset Requirement. Income for those who qualify for Medicaid is usually only their Social Security monthly amount. Assets is typically for those who qualify only the little that is in their checking account at that moment. I have the current chart and would be happy to let anyone know what those requirements are. There is also another program called Medicare Extra Help or LIS, and that is a Federal Program as opposed to the State program Medicaid. The income and asset requirements for Medicare Extra Help are easier to qualify for than is Medicaid. That program will also reduce the cost of our medications to a very small amount.

If a person can't qualify for Medicaid or the Medicare Extra Help (LIS) they may get help from the medication manufacturer. Most Manufacturers have what is called PAP or Patient Assistance Programs. You go to the Manufacturer web site and can apply online, or you can call them.

Finally if the Patient Assistance Program isn't available to a person, the Manufacturers often will help you apply for Grants.

For those of you who face Chemotherapy, Chemo is covered by Medicare Part B not Part D. If you have a Medicare Supplement, depending on the letter of the Supplement you might pay nothing at all for Chemo. If you have Medicare Advantage instead of Original Medicare and a Supplement, then the Medicare Advantage plan will cover you for Chemo through Part B too. Unlike the Supplements with Original Medicare however, you will be subject to the Total Max Out of Pocket for that specific Medicare Advantage plan. They vary a good bit from one Medicare Advantage plan to another with some HMO plans being as low as $1000 and Some PPO plans being as low as $3400. Those numbers will vary widely depending on the company and the State you live in for the specific Medicare Advantage plan.

I'd be happy to provide more info on specific situations for anyone who cares to ask me.

Carl

[DoriZett in reply to wizzard166]

A good man to have in our back pocket - thanks for all the info!

[wizzard166 in reply to DoriZett]

Whenever I've seen a post in our group about Medicare, I've always answered. It of course is second nature to me by now, and I've prided myself in becoming as knowledgeable as a human being can be. So why not help my other members of our group.

Carl

[gardening-girl in reply to wizzard166]

Carl, it is my understanding that treatments that require an infusion are covered by Medicare B, but oral treatments are covered by Plan D, that is unless the same drug can also be administered by infusion, and in that case it is covered by Medicare B. It makes no sense! I.E., it is not the class of the drug, chemo or immune therapy, but the mechanism of administration that determines coverage by Medicare B or Plan D. Is that your understanding as well?

[wizzard166 in reply to gardening-girl]

The rule is easy to understand. If a drug is administered in a Provider Setting, it goes through Part B. That same drug if a person obtains it from a pharmacy and injects or infuses themself is then Part D.

One of my Members when I first met him a few years ago was getting a drug that is injected for MS. He obtained it from a pharmacy and was self injecting. I suggested he ask his Rheumatologist if they would obtain it and have him come in for the injections. That alone could save him thousands of dollars; assuming, he listened to me and kept Original Medicare and got a Part D Rx plan instead of Medicare Advantage.

Carl

[Donnamccll in reply to wizzard166]

Carl, can you recommend a good Medicare supplement provider? Enrollment is upon us and I want to make sure I find a CLL friendly company.

[wizzard166 in reply to Donnamccll]

Donna

When it comes to Medicare Supplements there are many good providers, and no one Medicare Supplement company would be better with CLL than another. The reason is that your Primary Insurance will be Medicare, and it is therefor Medicare that will make the decisions on whether or not benefits offered with Parts A and B are covered services and also if the request for a benefit meets the diagnosis code. The Supplement companies are just Secondary insurance for you, and they do not ever accept or reject a benefit request like tests, therapies, surgeries, treaments, etc. The Supplement company will cover whatever Medicare itself approves.

When choosing a Supplement company we should look at the specific type of Supplement that we feel meets our financial needs the best. Supplements are designed by the government, not by the company that sells the Supplements. The government, not being too creative with names, has labeled the different Supplement types by letters: A, B, C, D, G, F, etc. Frankly its a bit confusing to so many people because the good old Government also names the different parts of Medicare with letters A, B, C, D. Basically, each Letter Supplement has a separate structure which either covers each benefit in Parts A and B or does not. Then even if the letter Supplement covers a specific Medicare Benefit in Parts A or B, it doesn't necessarily cover 100% of what Medicare allows but doesn't cover completely.

When you look at the chart that shows each letter Supplement, you read vertically from top to bottom with the Letter each different Supplement appearing at the top of the chart. Then you will see check marks going from the top benefit listed on the left of the chart to the bottom benefit listed. Then it is easy to see which letter Supplement covers all of the benefits and which ones do not. When you look at that type of Medicare Supplement chart, it is very easy to see that the only letter that covers every benefit is the Supplement Plan F. The next best is easily seen to be the G, and so on. Then there are Supplements with deductibles, such as the High Deductible F and the High Deductible G (HDF and HDG), and frankly those specific Supplements have the lowest price and might be the best structure of all of them.

When looking at the pricing with different companies of a particular letter Supplement, such as the Plan F for example, always remember that if its an F its an F. In other words whatever company is offering the F, regardless of the price they are quoting, is offering the EXACT SAME BENEFIT STRUCTURE. So the lowest price for the same letter Supplement from the different companies is the best buy for that letter Supplement.

Carl

[Donnamccll in reply to wizzard166]

Great, Carl! Appreciate your help.

[wizzard166 in reply to Donnamccll]

Donna and all others interested in Medicare

I forgot to mention in my educational post on Medicare Supplements, that the Plan F I've mentioned is only available these days to those who already were age 65 by January 1, 2020. That is because Medicare eliminated the F for sale to all others than those who met the age and date requirement. Those who had the F already or the HDF were of course Grandfathered going forward.

Younger people today can only get the Plan G, but the only difference in the G and the F is that the G doesn't cover the annual Part B Deductible. In 2023 the Part B annual deductible was only $226, but keep in mind that the changes in that Part B Deductible are controlled by the Government. If they felt over time that they wanted to raise it to three or four thousand dollars per year, there is nothing to stop them from doing that.

That is why I have been strongly urging those I help who are now retiring and old enough to get the Plan F, that they would be very smart to do so; even if, the price on the G seemed to make sense to take it over the F. Keep in mind that the companies, who make profits, would rather see you with the G than the F.

Carl

[Donnamccll in reply to wizzard166]

Thanks Carl. I'm 67 but purchased my supplement from USAA, who contracted medications with Wellcare. I still work, and was thinking about picking up some company benefits to assist if I need treatment. So far, only IVIG but my hematologist has managed to document appropriately and my cost has been minimal.

[DoriZett]

You received some very detailed responses. I would also like to promote TriageCancer.org as an excellent source of information for people navigating finances, insurance, Medicare and all things legal regarding cancer and cancer rights. Lots of "one sheets" of info on various cancer topics and webinars, too. All the best to you.

[craterlake]

Great question ... i have medicare part A+B and i am in the D category for drugs in part B ... then this wonderful group pointed me to organizations where you can apply for grants if you are low income .. such as the LLS and the PAN foundation etc. so i have received grants for thousands of dollars over the years that pay for my co-pay of medicare ...consequently i have never had to pay for the chemo drugs .... and LLS will also reimburse you the cost of part B medicare . Amazing ..... what a huge blessing .. a life savor actually .... without these programs i would never be able to afford these drugs except for the steroids ... and antibiotics ...i still have a co-pay for some of the tests and treatments but very affordable ...... at the rate i was going down hill at my first visit to my oncologist he said i probably only had a 1 1/2 years left ..at best ... and wanted me to start calquence that very day ... i declined until i had more info about side effects and financial assistance for the drugs which , thank God , i found from the wonderful people on this site ... so now years later i am doing remarkably well ... and might be MRD by january ... may the Lord bless you as well .. james

[MyCLLJourney]

I recently started with Zanabrutinib. I was concerned about the cost, but knew there were organizations that could help. I received a call from my prescription plan that said they approved me for Brutkinsa. At the time, I didn't know that was the same as Zanabrutinib. In addition, they approved me for a different milligram dose than what my doctor said he was prescribing. Then, a couple of hours later, my husband got a call from the specialty pharmacy and asked what our income was. We told her what it was and 1/2 hour later she called back and said I was approved for a grant. No income verification was done at all. Very easy, but I did have a lot of confusion when it first started. Apparently, the income limit is under 100k, but could be different for different organizations. And that is all they looked at was income.

[beanlake14]

I just got on to ask some of these confusing Medicare questions. I am trying to figure out if I should cobra my work insurance or switch to Medicare. I am currently MRD negative and on monthly IVIG infusions. How well does Medicare pay for gamunex? I worry about when I relapse as I will probably do Venetaclax again and some new drug not invented. By the time I pay for all the Medicare costs and my out of pocket expenses, I am wondering if I should just cobra at about 800 a month and get on medicare next year if total out of pocket will go down in 2025. Any ideas? Anyone on IVIG and on medicare? HELP!

[mrsjohnpaul in reply to beanlake14]

I don't think you can go on cobra if you are eligible for Medicare. Better check it out.

[lankisterguy Volunteer]

Hi Txsgrl,

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This reply from 2 days ago may help you with Medicare info: healthunlocked.com/cllsuppo...

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Len

[Katie-LMHC-Artist]

I’m on Acalabrutinib. I also have Medicare. I am getting free medication from Astra Zeneca. If your going on this drug in order to get free medication go to AZ&Me to look at the income criteria. I believe the cap is around $72,000 income per year. If you make less than you would qualify. Work with a financial navigator through your oncologist office if one is available. They do the work for you to find what financial help you would qualify for. Hope this helps!

[Monetfan2017]

Carl, many thanks for your detailed Medicare and Plan D coverage. Do the drug costs you noted change depending on whether the pharmacy is in or out-of-network?