My husband is Medicare eligible and currently on watch and wait, but he is nearing treatment most likely with a drug such as Imbruvica or Venetoclax. Does anyone here know how these new drugs are classified per Medicare? If it is considered chemotherapy, it is apparently covered at 100% under Part B. If it is considered a pharmaceutical and covered under Part D, there will be a high out of pocket cost.
If anyone is familiar with how this works I would very much appreciate your input. We're trying to make the best decision financially and open enrollment will be closing soon. Thank you for any assistance.
Colette
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bingbang
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i suggest you read all the posts already on this . Many just in the last 4 days. It is a part d drug. The total calender year co-pay is 10,000 dollars. Part d has a HARD RESET every January first. this might help understand
Thanks so much for the tip. I searched on Medicare and found a number of different posts. I can't say I'm happy with what I'm reading, but at least I have learned some valuable information to help us decide next steps. Thanks again!
Unfortunately, I tried that and the insurance companies do not consider Imbruvica, or drugs like it, to be chemotherapy because it is not a chemotherapy drug or agent. When I went shopping for Medicare Advantage Plans or Part Ds or Plans with drug coverage I found it best to shop these supplemental plans only by putting in the drug Imbruvica. It is a Level 5 or 6 drug and still has a 5% co-pay after all coverage. There are very few deals out there - lowest cost I found for my out of pocket was $600 a month. My out-of-pocket cost now even with some support is $950 a month. I did find some relief from grants that my oncologist helped me locate - to the tune of $5,000 a year. The drug manufacturer also has relief program if you apply and meet certain income tests. Our retirement is 90% social security, so I am going to try to see if the manufacturer will help us. We have no wiggle room in our budget, no play money at all, so we are beating the bushes and knocking on every door.
i just started with the jandj foundation. manufacturers by law cannot deal with medicare people directly. However they have set up charitable foundations.
Johnson and Johnson will help through their foundation, but you have to answer seven questions, must be treated by a U.S. Licensed doctor, must be a U.S. Citizen and being treated as an outpatient. They have an income test which will vary based on the drug in question. For their blood thinner the coverage is for households with annual income under $50,000, but for Imbruvica the income needs to be under $101,400. I hope this helps you BingBang. Michael
I talked to Biologics billing and received about the same info. The cost would be about $100.00 a month if your income level is about $100,000.00 per year. Less with lower income. There are various assistance programs for this drug that are well funded. The best Medicare supplement plan I could find was a little over $10,000.00 per year. More in January until you hit the catastrophic expense limit.
Does anyone know how they determine income? Is it taxable income after all deductions, or gross before deductions? They ask for a tax return, so wondering what figure they use. Our income went down this past year and we might be borderline for qualifying now.
They use the bottom line you receive in the last line on the 1040, For example, to be brutally open, our combined household income is $74,000 US currency. Of that $36,000 is social security. Neither the state or federal government treat that as taxable income. But JandJ likely have a different attitude - after all, taxable or not, it is "income" in our household. You can see why our country needs to get off the mark on covering catastrophic drugs. I doubt we will ever see national healthcare in our lifetimes, but I would be very grateful for just some relief on these drugs.
Thanks everyone for the additional info! I can see this is going to require a lot of research and reaching out to find any available resources. But at least now I have some leads to begin this process and I have some hope that there is help available. Thank you again for sharing
Wealth is not better than Health ,instead of indulging in this sort of affairs one gets delayed of life saving procedures .I humbly suggest go ahead n than afterwards the monitory gains things.Wish you all the best. Good luck
I will try to answer your original question about "Does anyone here know how these new drugs are classified per Medicare? "
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Any drugs administered by a medical professional are covered by Part B, and the 20% copay can be covered with a Medigap/Supplement policy. (Cancer patients can get this coverage the first time without disclosing pre existing conditions- but changing plans or companies is extremely difficult after the first policy, due to then having to answer questions about pre existing conditions).
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Any drugs self administered (e.g. taken at home) are under Part D and the copays are out of pocket. Drug companies are prohibited from giving discounts, rebates or financial assistance directly to Medicare patients, but they do donate to charities like the PAN foundation etc. rxassist.org/patients/res-c... or lls.org can help you navigate to find copay assistance.
just a small correction. there are some tablets -like prednisone and methotrexate-that are covered under part B. Just about any drug used for cancer before medicare part d started that were covered in tablet or capsule form by part b are still covered by part b
These regulations seem to change almost daily. Whereas ibrutinib is technically a chemotherapy being a chemical agent and not radiation therapy or surgery. The medical field considers the inhibitor drugs to not be chemotherapy, which works very well as patients are not as afraid of a drug not called chemo. Part B covers hospitalization which includes chemo as they are administered by infusion medications through an outpatient facility. Part D covers pill form of medications. Ibrutinib is in pill form and covered by Part D. Part B would cover hospitalization from side effects of inbrutinib. real mine field. Blessings.
I can't thank everyone enough for their input on this subject. Part of me almost thinks that they make this (shopping for Medicare coverage) confusing on purpose! Learning about donut holes, co-pays, advantage plans vs. supplement plans, Part B vs. Part D, researching private foundations for assistance...whew! And all under time constraints. Even more overwhelming when dealing with a chronic illness and other daily responsibilities at the same time.
But we will get through this, too. And am trying to focus on the things we have to be grateful for; things could always be worse. Very grateful for this site and all of the insights everyone has shared. This will go a long way toward making this "journey" a little smoother. Thank you again so much!
Medicare Part D only came into existence in 2003. It almost did not pass because of 'budget hawks'-on both sides of the aisle(yes some democrats are budget hawks). Also special interests (mostly manufacturers) also contributed to both sides of the aisle.
To make it palatable budget wise the deductible/co-insurance/donut hole/catastrophic system was passed.
AT the time all drugs-both oral and intravenous that were considered cancer drugs WERE covered under part B.
it's only now in the 'expensive novel drug era' that the weaknesses in the original system have popped up.
The original legislation also made it 'illegal' for a drug manufacturer to offer any kind of incentive to get someone to request their drug. Thats why the co=pay cards offered to private insurance holders cannot be used with part d today.
That gave way to co-pay charities that a manufacturer could contribute to indirectly.
I was a retail pharmacist when part d actually started in 2006.
Get Medicare plan F the most costly not by much but no co-pays. If its an infusion it will be paid 100%...Oral meds are partly covered on part D but contact the PAN foundation who gives grants to pay for the oral treatments.
Yes, we were planning to take Plan F as it sounds like this is the last year that plan will be offered and my husband would be eligible. But the Part D is what's making us hesitate. He had some infusion treatment in the past with no results, then went on Imbruvica with excellent results - but had a cardiac arrest. He is still in some sort of remission after almost two years, but treatment is looming once again. CLL specialist is leaning towards Venetoclax so that is what we're trying to plan for. The unknown costs are scary!
Im not sure if any part D will pay well for oral treatments. My husbands Hematologist has a pharmacist who connected us with the PAN foundation panfoundation.org/index.php... which gave us a grant that paid 100% for the Imbruvica and now the same for Calquence. His Medicare is paying for the Rituxan infusions with no co pay. He had to go off the Imbruvica due to AFIB and is now on Calquence that is similar to Imbruvica but with less chance of heart side effects
Johnson& Johnson will help with the cost but u have to meet a 4% out of pocket ( only for your husband) and this goes by your income. Pan foundation and LLS will be able to help you. The pharmacy where I get my imbruvica diplomat told me they will help me find funding if I didn’t get grants. Imbruvica is covered under part d and is around $640.00 copay per month. The first month copay is around $3800.00 and then you go into the catastrophic stage . Any other meds like insulin, eliquis will cost less Insulin about $ 30.00 and eliquis the same I wish you Good luck in your search
OK-it’s killin’ me! All these conversations regarding Medicare D coverage... So I’m on W&W, working on the “bucket list “ -I’m 67 and my love is 72. 13 Q mutated- Figuring that we need to complete all those physically demanding trips while we can: Spent some of my 401 to see the USA this year (10,000 miles on on a Harley TriGlide , US National Parks etc Want to cross the pond next year to explore England, Wales, Scotland and Ireland 🇮🇪 (100% I am!💕🍀).
Anyway...am I to understand that We need to get rid of everything that we’ve worked our life for in order to qualify for catastrophic MedD?? Who can truly afford 10K per year for these drugs? Feel that I cannot be held hostage-just not right! We’d sell our house, get a travel trailer and move near a big city drug trial!!! Call us crazy, I guess... are we?
I'm not sure I understand you, but qualifying for assistance is based on income not assets. You shouldn't have to sell your house or drain you 401k to qualify if your income is low enough ( approx. less than 100,000 for ibrutinib with Johnson and Johnson)
Thanks for your message John. I guess I was thinking that when you do tap your 401 i.e. for travel, it is counted towards your income and I pay tax at the time of withdrawal. Who knows the future? Maybe the cure is truly right around the corner and perhaps not a financial burden as we dread. For now, I’ll continue to W&W and live life to its fullest-sorry for the whine....sometimes thoughts of this crazy disease get the best of me.
A couple of legal clarifications from a fellow CLL patient (successfully on ibrutinib) and longtime Social Security attorney:
1. Social Security and Medicare are insurance programs. You (and your employers) paid premiums through payroll taxes for your benefits, to which you are contractually entitled regardless of your financial circumstances. It is not welfare. Your other income and assets are irrelevant to your right to receive Social Security and Medicare benefits. Millionaires can enjoy the same entitlement.
2. Distributions from tax-advantaged accounts like 401ks and traditional IRAs (but not Roth IRAs) are taxable as income and may increase the percentage of Social Security benefits that are taxable. Therefore, when applying for funding it can be important to know how "income" is defined.
however the applications are being given to 'charities'. Technically can't they make their own rules. co-pay HELP from a charity is not the ;insurance itself'
My husband is doing Gazyva infusions and Ventoclax, we applied for a grant at the Dr. There were no questions about income, but said if he went on Medicare it went away. They contributed towards the infusion drug and the V is $5 a month copay. He met his out of pocket so now insurance covers all infusions until Jan 1.
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