Question on Medicare Part B vs Part D on Lupron, Xgeva, and subsequent PCa drugs

I started Lupron at age 64 on 3-28-2103 and paid my 30% co-pay thru my high deductible PPO plan.

I turn 65 in August, thus Medicare eligible on 8-1-2013 and making my Medicare age 65 elections now.

My choices will depend a lot on whether Lupron, Xgeva and probably some day other drugs like Casodex, Avodart, Luekine, Ketzconazole, Estrodial, Xtandi, Zytiga, Provenge etc. are considered Part B because some or all are administered by a physician or part D because they are drugs or some combination of each.

Can some of you under Medicare advise how your particular treatments are treated by CMS/Medicare. I understand there may be some pre-approvals required depending on the plan, but that will not be an issue in may case getting the medical oncologist at Univ of Florida & Shands to recommend the proper treatment.

It's looking like I may soon learn personally about the Medicare Plan D donut hole with these expensive drugs, but if they do the job, money well spent, since we can't take it with us.

Since my 4-month Lupron renewal is July 28, I have flexibility whether to do the next Lupron before August 1st since I likely will have maxed out on my maximum $5k out of pocket on my PPO plan by then, or after July 31 when it is covered under Plan B and/or Plan D.

I might opt one way if it plan B but the other if it is Plan D. Ditto for when I start on Xgeva.

The other drugs will be more of a question for 2014 Medicare enrollment or later.

Thanks Redwing57. I noted on prior posts that you are only about age 55 @ Dx, so unable to answer my Medicare question unless that were your field.

Yes, continuous and maybe Intermittent HT someday in 18-24 months are my current options. There are different schools of though on whether to remove the prostate but I have metastatic bone disease in spine (2 tumors), also in 2 tumors on right posterior ribs and one tumor in right sacroiliac, not to mention right PNI on initial biopsy, but fortunately no symptoms other than what shows up on biopsy and bone scan.

Medical Oncologist said to radiate my way out of this pre-ADT would be like Chernobyl.

The good news is that only about 1% of us are diagnosed with bone mets on initial biopsy rather than as a recurrence. So this early detection with only 5 visible on regular bone scan (doctors have not said anything but I am pretty sure there are more bone mets and lymph node involvement if we used F-18, C-11 etc diagnostics), UF & Shands considers my case to be treatment with curative intent (Oligometastasis <=5 bone mets). rather than palliative (if I have pain) one step before Hospice

Thanks 142.

That's what I was thinking too with respect to jamming as much as I can in before August 1st, and dealing with the devil I know rather than an unknown.

The break even gets harder to calculate if I defer joining Medicare beyond August 1st, since there is a lifelong I believe it's 10% penalty if I defer joining at age 65 and then join Medicare later. My retiree benefits plan is not all that good, vis a vis Medicare, since I am paying over $1100 per month for spouse and me, other than I have maxed out the out of pocket.

The other thing of course is theoretically the Xgeva is doing some good, or at least as we discussed in other thread preventing some further bone damage. So there is a longer term benefit starting it earlier than leveraging some short term cost avoidance.

So I am doing the DEXA bone scan Monday to get a baseline. Depending on that result, starting on Xgeva is more a case of finding a time when we are in town on consecutive months, as grand kids keep us hopping, than it is of leveraging current insurance now versus Medicare in August.

You are right about Part D too. The plan that may work best for me now for balance of 2013 from August 1 to Dec 31 may not be same one that makes sense for the full year 2014 and that enrollment starts in mid-October before I have had a lot of experience with CMS/Medicare, or the part D provider I end up choosing.

Then in future years as I most likely need testosterone resistant cancer prevention drugs given the unreliability of my PSA as an indicator, my Gleason 9, bone mets and right PNI at initial biopsy, there may be yet a third Plan D that is optimal, and that's before the ink on Obamacare is dry.

Thanks for helping me think this through and I look forward to hearing from folks who have fought the Medicare battles on advanced PCa treatments, especially ADT, triple action HT etc. since at moment neither radiation nor surgery are in my immediate future.

Thanks, Quincy.

My Eligard (same as Lupron) was covered by Medicare part B.  My Medicare booklet says that a limited number of drugs like injections you get in a doctors office and certain oral cancer drugs are covered. Other than these examples, you or your Part D will pay 100% for most prescription drugs. 

I'm curious if you have decided on a Medicare supplemental (medigap) policy.  Picking the best plan for ones  personal circumstances is confusing to say the  least.  My wife and I have been on Medicare for over 10 years and I still don't know which plan might be the best for us over the years ahead.

I live in Pensacola and am very interested in learning more about the UF and Shands Metastatic program.  Is this the one located in Jacksonville?  If so, that wouldn't be too bad a drive from Pensacola if I ever need it. 

Carlos

Carlos, check out this prior thread which is where I found out about UF & Shands

https://www.healingwell.com/community/default.aspx?f=35&m=2245716

Up until that thread and a similar one on Inspire.com and then a Dr. Charles Myers' video on prostateforum.com, my entire team was telling me I was treatable but not curable, palliative for pain and eventually hospice.

All were overly relying on some very vague CYA wording on the bone scan (multiple thoracic vertebral bodies and right posterior ribs) without actually looking at the scan itself. I had an electronic copy but did not know how to interpret it.

It was the UF & Shands questionnaire that asked specifically how many tumors, a question I could not answer from the bone scan report. Had a heck of a time but eventually got the radiation oncologist to look at the scan itself and declare though subjective at most 5 bone scans in his opinion.

I go to Gainesville which is a couple hours closer for me than JAX, but the newest VERO equipment (2nd one is US with MD Anderson in Dallas being the first) is in JAX.

Here's a You Tube - http://www.youtube.com/watch?v=UGt62HgRz1o

My spouse and I will wave to you in Pensacola, Jeff in Louisianna et al as we make a 5-day drive from FL to San Jose soon with 2 dogs in car.

Carlos - on the Medicare decision, we are leaning toward either a Plan F (I think it's $169 per month in our zip code at age 65 entry) which pays almost all the deductible and Co-pays or a Plan N that is similar but does not pay the $147 plan B deductible or the $20 co-pay so has a lower price ($122 a month in our zip code for age 65) from which we can calculate a break even.

Since we can afford it, I would just as soon cap our costs and pay monthly in a pay me now pay me later scenario. It has to be cheaper than the $1100 we are paying now for a retiree high deductible PPO until end of July when I become Medicare eligible August 1st.

It may be a different choice for my age 65 election from August to December than it will be for 2014 (have to decide that between Oct 15 and Dec 7) before I even know how good our age 65 election is/was from Aug 1 to then .

Medicare for years beyond may be yet a third decision based on some other very expensive drugs if I experience testosterone resistant cancer, I should say when rather than if with my metrics.

All require some sort of Plan D and that is why I started the thread. With no restrictions at age 65 entry, I may opt for a high end plan since my drugs only get more in quantity and cost as time marches on.

Impact of Obamacare is an unknown.

Some people use part C (which has different flavors of A+B+/-D) and add on a cancer policy and AFLAC, but not sure that is an option for those of us already diagnosed with PCa. I actually have yet another meeting with a Medicare sales team on Monday to discuss that.

I don't want an HMO as I want to have a choice of doctors but would not mind a PPO where I could go to any Medicare approved doctor for a slightly higher co-pay.

I'll let you know where we end up, not that I am any kind of expert on the matter.

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I ended up with a modified Plan F that is a little cheaper than a straight Plan F and my spouse was able to go Medicare Advantage (Just the plan B premium with A/C/D all zero) with an AFLAC like policy and a cancer policy that pays you back the difference between sum of premiums paid since inception less cancer claims in 10 years at age 75.

Lupron Jim. Did you make your medicare decision? My husband took plan N supplement and pays $20 only when he sees doc, not for any chemo treatments or provenge. Anything injected or IV in doc office is covered under B. in FL pill chemos are under Part D. There are philanthropic funds that help with copays for part D drugs. Our oncol office got us into the first one. When they had no money in Jan 2013 to cover xtandi and the donut hole, I found another fund on line that covered all but a small amount. Now he changed to zytiga pills and the fund does not cover that drug. Our oncol office found another fund and he has money allocated to take him into 2014 through the donut hole if he continues on zytiga. Many of the funds only consider your income and NOT assets. Some qualify with almost twice poverty level income depending on fund. If you have selected an advantage PPO plan, you will have higher copays but probably have an out of pocket maximum, again for injectable or IV drugs. If you did not sign up for the supplement plan within your time frame, I think they can reject you later on. Without the philanthropic fund help, we would be paying well over $10,000 for drugs under plan D. Our oncol office has statewide offices and their own pharmacy with knowledgable employees to help locate financial support. Let me know if you want to chat via email and I will unlock my personal email on this site. Hope this helps and not too late.
Pat

Dreamer44, after seriously considering Plan N that probably would have been cheaper since it takes a lot of $20 copays to make up for the difference in premiums, we opted for a modified Plan F.

Plan F pays all the deductibles and the only difference is modified Plan F only pays for certain doctors locations and hospitals, but my main facility UF & Shands is one that is covered by the modified Medicare Plan F.

As Zufus indicates these drugs are extremely expensive and I wanted the best Medicare plan possible given the likelhood that someday I will sample most of the PCa drugs. Your Plan N does the same.

Fortunately this dread disease usually affects older men, but there are exceptions with guys in their 40's and 50's. Has to be a terrible financial burden that accompanies an already teriible disease, but in life or death situations one does what one has to do.

LupronJim