After being in Social Security Disability Income due to MBC, I’ve been automatically enrolled in Medicare. The coverage starts on 1/1/2025 and prescription drugs are not covered. There are separate Part D Prescription Drug Plans that must be purchased, if you want coverage. I’ve been reviewing all the options and checking formularies for the drugs I’m taking, but still having difficulty deciding. I thought I would ask the group, since many of you may be covered by Medicare, Medigap and PDP plans.
For those who live in Massachusetts, which Part D Prescription Drug Plans offer the best coverage for metastatic breast cancer drugs? The plan has to be purchased during open enrollment which ends on 12/7/2024. Please let me know, if you have any guidance to offer on this matter.
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MettavivorDS
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I’m on Medicare, but not in Massachusetts. Don’t forget that some of the drug companies have patient assistance programs and if you qualify, you might pay nothing for your drugs. I received free drugs from Pfizer and Lilly. It’s really worth looking into. Especially since those were super expensive drugs. I think they were Ibrance and Verzenio. Good luck!
Beginning in 2025, Medicare Part D covered drugs (which your cancer meds likely are) are capped at $2,000 for the year as part of the Inflation Reduction Act passed earlier in the Biden Administration. While $2K is still a lot of money, this is a real game changer for many of us who have had to pay more than that monthly for some of our cancer drugs even within our Medicare plan. I think the rule should hold for specialty pharmacies also, but here are the details if you want to read further to validate: medicare.gov/drug-coverage-...
Yes it holds for specialty pharmacy. Any drugs you buy are counted in calculating your out of pocket expense. This year the limit is approx 3300 and as soon as I hit that with my specialty pharmacy, my drugs were free.
In general, you need to run your drugs through the Medicare comparison program and see which plan is cheapest for you. Even with the 2000 max next year, I noticed that there were some plans that were higher than that. I ended up with a WellCare plan, but I’m not in MA.
Hi! I use WellCare and are on teir 5 drugs. Biden has a fantastic CAP on Medicare oop drug spending of 2k. So after you meet your deductible on well care, my medicine is 16,000 a month but I will pay 2000 for the whole year. Thanks to this Medicare out-of-pocket cap.. I pray the next administration does not mess with that:(((
When I first went on Medicare, I found an inexpensive plan, but that company went under. Then I went on Walgreen's something -- I never got my meds there; it was the name of the plan. Now I am on AARP's Medicare Part D, which is handled by United Health Care (whose head was just murdered, that one). You still have to choose a plan, from more expensive to less expensive.
I have gotten my most expensive cancer meds through patient assistance programs. Then they are free. Your oncology department has to help you apply and your income has to be below a threshold, but it is a pretty high threshold.
Basically, when Part D got added, under Bush 2, it was left private, no caps on prices. Finally, that is fixed. With these expensive cancer meds, you can fall into the donut hole easily, where you have no coverage until you have spent a lot more. Biden just fixed that.
The other hidden wrinkle in drug coverage is that prices are really set by middlemen, between the pharmacies and the pharmaceutical company. Small pharmacies, not in chains, have no bargaining power and not enough volume to make up deficits on particular drugs. As a result, many are failing. I was going to a chain pharmacy until recently, when I needed a particular generic and the big pharmacy was mandated to supply only one generic, not the one I wanted. The nice pharmacist told me to try a small pharmacy. On my mile long walk home (in NYC), I stopped into each pharmacy I passed. There are many. Nope, nope. Then I hit one a couple of blocks from me where the pharmacist looked it up and ordered it for me. I switched my business there. (That is another thing -- one generic of exemestane made me really sick; another one had almost no side effects. I found out by accident when I was away for a month and went to a different pharmacy while on vacation. Voila.)
Another thing is that when I went on capecitabine (Xeloda), it comes out of Medicare, not Part D, because it is considered chemo, even though it is a pill. I still get it from a specialty pharmacy, but the co-pay is low.
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Ibrance expensive
COST OF TREATMENT !
Optum Rx
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