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Posted 3/7/2012 1:04 AM (GMT 0)
Got a question that actually stems from Todd's battle to get his HMO to cover Provenge.

There are a bunch of brand new drugs that cost a HUGE amount. I think I read today that provenge is $93K. That is outrageous.

Consequently, insurance companies seem to go out of their way to disallow such treatments.

My question: when the FDA approves these drugs, does that mean Medicare automatically covers them (assuming the drug is deemed appropriate by the oncologist)?

You know, I am eligible for Medicare but I've been advised not to enroll because I work and my excellent work insurance is primary. But I have not yet gotten to where is need such newer drugs (but that could happen easily in the not too distant future). Should my insurance not cover such a huge expense, I could see retiring just so Medicare becomes my primary insurer. What a revolting development that would be.

Any thoughts/information?

Mel

Posted 3/7/2012 2:32 AM (GMT 0)
As I understand it (I'm not on Medicare, but my Mom is), drugs are approved regionally by companies that are contracted to manage Medicare in those regions. There should be no assumption that FDA approval means Medicare approval.

I remember this primarily because Provenge was not approved everywhere at the same time, and I did a little research, as I was considering applying for disability.

I have also been told that "generally" my employer's insurance company drug coverage is dramatically better than Medicare. We have a number of over-65 employees who would not go near Medicare for any reason. In fact, if we sign up for Medicare and the drug coverage part, we have to sign a waiver and legal acknowledgement to give up company coverage. There is a reason based on some ugliness in the past for people who wanted to come back into the plan.

 

Posted 3/7/2012 2:41 AM (GMT 0)
I have been on Medicare as my primary since July of last year, couldnt be happier (as the result of getting put on SSD). They are covering much better than when my wife's BCBS was the primary. Medicare pays for 100% of my re-hab - no copays, 100% of my urostomy supplies (which run $300 a month), since I made the swtich, my oncologist's office has never billed me for a dime. I am using the AARP version of the Medicare drug plan, and has greatly reduced my monthly prescription costs. Right now, I have nothing to complain about. None of my doctors have seemed to mind the switch to Medicare for me.

david
Posted 3/7/2012 2:54 AM (GMT 0)
The problem with Provenge is the cost / benefit ratio..
Posted 3/7/2012 3:07 AM (GMT 0)
David accidentally brings up a very serious point.

None of my urologist/surgeon, RO, GP, or dermatologist accept Medicare. Urologist, RO, and dermatologist accept Tricare, but I don't qualify for that. That would be a big consideration in moving to Medicare - changing doctors.

Also, the wise choice of a supplemental & drug plan is far beyond critical. My cousin was in a nursing home for end of life care. Her plan covered all the things that she needed. There were other patients whose families had picked the cheap/limited plans, and were left on state aid after the home was sold and bank accounts emptied. I visited with a lot of folks there whose families would not come see them out of the shame. Scary situation to see in real life.

Posted 3/7/2012 3:17 AM (GMT 0)
142 - didn't know i was accidently doing anything, lol. I should add, I did not lose or have to change any doctor on my medical team, which pleased me well. When I needed the orthopedic opinions last summer to rule out mets and to re-evaluate the pain issue, there was no problem with Medicare allowing me to see a top notch ortho specialist in my area. Same with the MRI's, bone scans, CAT's, no question asked. When my doctor wanted me to have some special PET scan, found out after the fact, it was BCBS that scrubbed it and said no, not Medicare. The dr's office accidently identified BCBS as my primary, when it wasn't.

At age 58, still at the time, I feel fortunate that I was approved for SSD, my fight with that was well documented on HW, and because of the delays in approval, I had already fulfilled the Medicare waiting time, so in my case, the Medicare kicked in within 30 days of approval of the SSD.

Again, not boasting, just feeling thankful and fortunate. For me, the system is working.

On the Provenge, if you only look at it from the cost point, it makes no sense. Like if you were doing a corporate cost justification analysis. But I don't look at medical matters that way. I feel every patient should be entitled to the same choices and same opportunties, i.e. treatment choices, meds, etc, including Provenge. I think what hurts the inclusion of Provenge, is the short life extension that is usually associated with it. Correct me, but I belive the median is 6 months? I realize that for some, it would be much longer than that. But for a treatment that cost 93K plus the doctor fees for infusion, etc, it is simply very, very expensive. I am not sticking up for the health insurance carriers, but one side of me can see their reluctance to embrace it..

david
Posted 3/7/2012 4:14 PM (GMT 0)
I have been on medicare through my PCa treatment I couldn't be happier with the coverage. When my wife was diagnosed with a tumor we went to MD anderson and medicare covered all the tests, surgery and doctors.
Posted 3/7/2012 5:15 PM (GMT 0)
Mel,  I live in NW Florida and we have 33 Medicare Part D Rx plans to choose from.  I'll use Zytiga as an example.  Zytiga is covered by all plans in my area and most will cost about $6300/yr including the insurance premium..  Humana Walmart says the drug costs $5666 per month.  With the $15/mo premium, $320 deductible, 30% copay and catostrophic coverage the annual cost would be $6156. The most expensive plan (BCBS) runs about $7363/year. 

Plan costs are a moving target and change every year.  Medicare.gov has a good drug cost comparison tool.  My wife and I run our prescriptions through the system every year and change plans as necessary to get the best coverage.

Carlos

Posted 3/7/2012 5:15 PM (GMT 0)
The problem with Provenge is the cost / benefit ratio..

with the new hep C drug they are saying it's cost effective only for those with the advanced disease so i can also see where that's headed.

ed

 

Posted 3/7/2012 6:19 PM (GMT 0)
To ALL, - Although it is true that a number of procedures and drugs coverage is decided on a regional basis by the individual organizations that are contracted to reimburse Providers on behalf of Medicare, it is also true that the Medicare Program can mandate universal coverage of specific procedures by these regional contractors. This is the case with Provenge, Medicare has now REQUIRED coverage of Provenge by all regional contractors.

Medicare has, as do most governmental programs, very complicated reimbursement provisions. First, the law under which it is authorized only provides for 80% reimbursement of the "usual and customary" fee for a procedure. The "usual and customary" fee figure is determined by the Payer, not the Provider. A Physician who accepts assignment of benefits, where he/she accepts payment directly from Medicare, is REQUIRED to accept Medicare's "allowed amount" as full payment and cannot charge more than that figure. Since Medicare allowances are often 'arbitrarily" determined, they have largely fallen behind the actual fees that are usually and customarily charged in todays delivery system. It is estimated that Medicare Part B, actually pays approximately 65 to 68% of actual Physician charges.

As a result of the mandated fee limitations, MOST Physicians do not routinely accept Medicare assignment but they are limited to charging up to 20% more than the Medicare determined, "allowed" fee, MC reimbursement is made to the patient ,who is then responsible for paying the Physician the full fee charged, as long as it is within the allowable 20% restriction. Here is a fictitious example: Dr. Fee charged = $120, MC Allowed = $100, Medicare Pays $80 (66.6% of actual charge) leaving Patient responsibility = $120 ($40 or 33.3% out of pocket)

This is just the tip of the iceberg but, I hope this is understandable. I haven't even touched upon the various supplemental plans paid for by the Medicare patient. Nothing is easy anymore! - [email protected] (aka) az4peaks
Posted 3/7/2012 7:29 PM (GMT 0)
az4peaks,  I have a question aout Provenge and medicare.  Provenge is covered under Medicare Part B as drug and is therefore not subject to the "usual and customary" charges  if administered in a doctors office or hospital outpatient and may actually be billed at the $93,000 price. This would mean 80% covered by medicare and the rest by the patient.  But, I also understand there are additional charges for collecting the blood and delivering the infusions.  These would be subject to the "usual and customary" fee determination.  Do you have any idea what the total cost to administer Provenge to a medicare patient would be?

Carlos

Posted 3/8/2012 9:37 PM (GMT 0)
Hi Carlos - As I understand it, Provenge is a Medicare part B covered drug and therefore subject to the 20% co-pay by the patient. As you describe, Medicare will be the Primary and the Private plan plan will be the secondary insurance coverage.

Advantage plans VARY in their provisions but, USUALLY, cover, at least the majority of the co-pay due from the patient, providing you use an approved "in-plan" Provider. The 20% patient obligation will be based on the Medicare "allowed" fee, as stipulated on the Regional contractor's explanation of benefits but the 80% is usually paid directly to the Provider.

FDA approval of a drug does not guarantee that it will be covered under Medicare and separate payment policy authorization needs to be taken by the Medicare Regional Administrator. If Medicare does not mandate the coverage on a national basis, the decision making process is left to the regional contractor's determination and can vary by region, as to coverage and payment provisions. In the case of PROVENGE, national coverage by ALL regions, has been mandated by Washington

Approval of coverage is based upon the FDA "on label" approval, which specifically states that: "PROVENGE is covered for men with asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer." Off label use is NOT approved as of this time and date.
Medicare, as of November, 2011 belatedly approved payment for the administration of the infusion, retroactively to July 1st, 2011. This charge is individually submitted for EACH of the 3 infusion sessions. According to a spokesman for Dendreon, the manufacturer, the fee for EACH administration has AVERAGED about $125 for EACH infusion but can vary by time involved. Provenge can only be approved for coverage ONCE in a patient’s lifetime.

I wish you good luck in meeting your future medical needs. I hope this helps, but, when and/or if needed, please verify all of the above information with your professional advisors, as things can and do change, but this is my layman's understanding of Provenge coverage under Medicare, as of this date. - [email protected] (aka) az4peaks

Post Edited (az4peaks) : 3/8/2012 3:02:09 PM (GMT-7)

Posted 3/9/2012 2:31 PM (GMT 0)
 

<<This is just the tip of the iceberg but, I hope this is understandable. I haven't even touched upon the various supplemental plans paid for by the Medicare patient >>

Coverages for all Supplement Plans (Medigap) are exactly the same; premiums, however, vary by the issuing insurance company depending on the specific sub-plan chosen, e.g., A-N. The critically important variable is the issuing insurance company's underwriting criteria. The best plans are age/area/experience rated NOT based on the applicant's medical history. This latter, I would think, applies to all of us here at HW.

In my particular case, USAA's Supplement Plan "F" satisfied the above criteria and is now in place. My understanding is the supplemental plan fits "over the top" of Medicare's typical 80/20 which, in effect, provides 100% coverage since there are NO co-pay's/deductible's. Also, the math makes sense in my particular situation since, as an understatement, the monthly bank draft premium of $166.30 compares favorably to the previous Cigna spousal group premium (wife's employer) of $538.00  mad . Drug Card, coverage D, plans are extra and require the same careful shopping as Medigap coverages.

FYI: USAA membership is extended to those of you with previous (honorable) active military service, or if you are a spouse/son of a USAA member.

Hope this helps some of you who, especially, are in the critically important planning stages.

Mitch in SC

 

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