Pharmaceuticals are not covered by Medicare. You need a Medicare Advantage Plan or a Supplemental Plan to cover pharmaceuticals. It's not easy to find out what you need to know and to figure out how to make a decision between plans. It also varies by state.
I suggest you start with AARP, where you'll find a wealth of information. They offer their own plans, but they also will help you gather information.
It's a long and winding road. And you have to act relatively quickly. You can't make this decision over the course of months. You need to make the decision sooner rather than later.
I suggest that after you get some plain language information from AARP, that you look around and see what's on offer from other providers in your state.
PS: Medicare isn't government funded. You've been paying for it out of your earnings from the first day you went to work.
You have several options within two main subgroups: Medicare Advantage is what I use because there are minimal copayments and the monthly cost is less for me. This option is not available in all areas - in this part of Virginia Humana provides this option and most (but not all) providers accept it.
The other option is called Medicare supplemental policy and is sold by many companies. Also there are several sub choices available with different out of pocket costs mandated for each plan. These are called Plan A,B,C - etc. The most popular is Plan F which costs the most and covers the most. Supplemental was the only thing available in the county where I lived. We chose this plan because you can go to any doctor you choose. Benefits are mandated by Medicare but cost companies charge for the insurance is open to competition. Most of them are within the same range because “competition”.
When we left California two years ago we were paying about $200 per month each, but virtually everything was covered in full.
Remember that with any option you still need to pay Part B and Part D (drug benefit). Part A everyone has to pay. Any of these costs to you are deducted from from your Social Security payments, but the supplemental insurance paid to insurance carriers is paid directly by you.
Complicated I know,but it works. For those of you keeping score it cost us over $350 per month each but everything is covered. And you thought Medicare was free!!
One last piece of advice: don’t trust brokers who solicit your account unless you have to. The best place for free info is medicare.gov they give you all of the info on your options including a list of the companies selling supplemental insurance and their prices. I know lots of folks won’t want to get that involved with computers and you may have to buy from a broker - or find a trusted friend to help.
Just for information I am a retired dentist and able to maneuver around government websites. I went through this all 10 years ago and really glad I don’t have to do it again ( I hope!)
This is one of the key reasons I moved outside of US. Here in Japan we have single payer system that we as a family joined and for myself ( retired) , wife and teen kid is about $50/month for the family and that includes medical, dental and vision. My copay is 20% but the actual cost of medical services is much lower then in US.
For example, I had just come back today from the hospital from checkup ( every 90 days). I had blood test, have seen Rheumatologist and Orthopedic Specialist. Blood test were done at 10AM and results were sent to Rheumatologist for my appointment at 11AM. I left hospital after seeing second Dr at noon.
Total cost (copay) about $17.
This is how efficient single payer system should work.
I've been on Actemra for about 10 months now. It sure is like trying to navigate a series of booby-traps to get the most bang for your buck.
I have Aetna-Medicare Advantage and pay nothing for my weekly injections. This insurance is through a retiree's plan from one of the Steel Mills in Indiana, though I now reside in Maine.
Do you know anyone who is a social worker? Possibly there is a social worker at a Senior Center who could advise you. You've received some great suggestions...but the reason I suggest a social worker is this. Last year after developing GCA, a friend who happens to be a social worker took me to Social Security and DHHS. She gathered my medication costs (at that time I was either on 100 mg or prednisone or 64 of prednisolone and useless) and I went along with her to those offices. Due to the high cost of the meds, I no longer have my Medicare premium deducted from my SS check. I don't know the name of the program because I do not qualify for any 'state benefits or aid'...?
My Actemra comes in a cooler each month from Apothecary by Design, 141 Prebble St., Portland, Maine 04101. Their phone is 877-814-8447. They ship overnight all over the US and I'm wondering if they couldn't give you some first hand info regarding plans as they pertain to this medication. They would be that helpful...they are really patient centered folks. Their email is info@abdrx.com , but I know they would take the time to chat with you.
I just re-read and you are talking infusion~! Sorry...got carried away. Could the Epi-pen work for you? You don't even feel it... and I don't believe it is as expensive. $1500-1700 each.
Do let me know. Do you have Spectrum Generations Senior Centers where you are...they are super helpful too.
I know your question is about medicare coverage and others have answered. I have a question for need for Actemra. As far as I can see you just started with prednisone in June this years. Is that correct? Then why on earth would you consider such a expensive replacement if prednisone is working? Prednisone is proven and you are on relatively moderate dose at the moment ( less then 15mg). If I were you, I would stick with prednisone at least for first 2 years and then you can revisit the issue, if you need.
I hope you sort it soon as it sounds like a nightmare to me. Definitely get the best plan for now and in the future.
OH has beenin four different hospitals over the last few months I would not have been able to cope or afford even part of the cost. Under very difficult Covid times we have had excellent treatment and care.
Make sure you sign up for Part D or later they will charge you a fee for not being signed up in the beginning. My mom has WellCare for Medicare RX.
She has Loyal American for supplemental insurance.
All I can tell you is my experience with Medicare. Have been on it for 16 years. It took a lot of reading and comparing plans for my supplement choice. My thinking was— this is like having insurance against a catastrophe, like a fire at your home or wreck in your car. But medical costs can be huge. I went the more expensive route, not an advantage plan with co-pays, deductibles etc. For me it’s been worth it, as have had many unexpected needs as I’ve aged. For my drug plan( part D) I chose cheap. Sorry. It is a personal decision involving homework. You can make changes yearly if needed so not set in stone. My best.
This is exactly why even though I’m 65 I stayed with my employer insurance since I work full time with no plan to retire here in the US. I saw a Medicare Specialist who I thought was extremely helpful/knowledgeable & lots of friends had recommended. She laid everything out for me to weigh out costs with no pressure either way.
Not as long as you continue to work full time & have health insurance. I did check this with multiple sources as well as people I know who did this too. It states this on the Medicare website too. My employer HR department said if I decide later to switch to Medicare they provide a letter to submit to prove I was covered.
I switched over to Medicare and got a supplemental plan through my employer's insurance, and my employer picks up all the premiums. Zero copays and zero premiums for me, and actually cheaper for them.
We discussed that option but I work for a large national corporation that uses a HSA to help employees pay for health care costs & that they offer a match. You can not use Medicare & a HSA so that didn’t make good financial sense for me. It’s all so complicated!
When I went on Medicare 25 years ago, I looked into supplements. As a healthy senior citizen, I looked at the costs of supplement insurance over time. I came to conclusion that I was better off with just Medicare part A and B and put extra money in bank , (mutual Funds) for a later time. I have never regretted it. I have been on prednisone for two year this coming December. I do not know about other medications. I tapered to 3mg. then had a hiccup, injured tendons in left quad, so have gone up to 5mg. because of trauma due to new injury. However, plan to start tapering again next week. Why try something new, if you have been on prednisone such a short time?
My understanding is that traditional Medicare covers Actemra INFUSIONS in an outpatient setting under Part B at the usual 80% and you'll want a supplement that covers the rest. If you want the self-injection form of Actemra it comes under Medicare Part D (prescription medicines) and you have to find a Part D service that will at least partially cover it. I strongly suggest you also visit the patient foundation website for Genentech which is the Roche subsidiary in the USA that supplies Actemra. You may qualify to receive the drug at no charge. Go to genentechpatientfoundation.com and look for the Patient tab. You can apply online, or by calling the number provided. Good luck to you.
I am from the US and I have Medicare as well. Most medication is covered by Part D as in drug. The rest of Medicare covers hospitalization, doctors appointments and other non drug-relate things ( such as Walkers or wheelchairs). This is probably why the infusion is the confusion. Pardon the rhyme. If Medicare says they'll cover it with Part B insurance take their word for it. typically you pay 20% and Medicare pays 80%. You will definitely need a supplemental plan. Never get Medicare without a supplemental plan. If you don't get one now you will never be able to get one. I hope this helps.
My heart goes out to you all in the US dealing with health insurance to get needed treatment. Having experienced that there and now living in a country with a functioning public system (NZ) it makes me angry there still doesn't seem to be acceptance that it's a good idea there for some reason.
The fact that you have to split your time becoming an expert in your condition plus an expert in medical finance -- it's a lot.
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Does anyone have experience of having to stop Actemra after being on it for several months and the effects of that?
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