Medicare Drug guestions

Hi all,
My husband will be applying for Medicare next month. Right now he is on 3 mo shots oF Zolodex. I know that the 2nd line drugs will mostly likely be in his future.
Can anyone give me some insight on drug plans and costs for the drugs like xdandi, zytiga,xodigo, and any of the 1st line ADT. I Have no idea what our drug costs will be with the Medicare plans.we live in NY.
Thanks

What Roblee said. Even with Medicare A and B, its worth the money to get a drug plan (part D) from an outside insurer. I went through AARP/walmart and have their plan. about $17/mo. Medications depend on tier levels. Some of my meds cost $8 for 90 days and others are covered at $0. Also some sort of supplemental insurance goes a long way in helping. Mine is costing about $170/ mo. There are plenty of insurance options out there. Find the one that best fits your needs, watch that donut hole thing and keep price in mind also. In some states, like NJ, the supplemental plans offered by different companies carry the same coverages. I'm currently getting Lupron injections and I'm covered at this point by Medicare.
For the best advice, find a licensed medicare agent.

LSil: I actually work one day a week as a Medicare counselor for my local SHIP provider. SHIP is the State Health Insurance & Assistance Program - a federally funded free state counseling program that helps seniors understand Medicare, Medicare Advantage, Medicare Supplement (Gaps), Part D RX programs, and financial assistance programs for income eligible Medicare recipients. I strongly encourage you to find your local SHIP program and speak with one of their counselors. The decisions you make about Medicare at your initial enrollment are critical, particularly when you know going in that you have chronic and potentially serious and expensive health conditions. This service is free of charge and not affiliated with any insurance company, drug company, etc. It is important that you exercise the same due diligence in this decision making process that you exercise in your treatment process. Some of the information provided in the responses here is good general information; some is incorrect.

First, prescription programs, whether they be free standing or embedded in an Advantage Program, are unique to the region they are sold in as to company, formulary, pricing for premium as well as co-pays, etc. You need information about what is available where you live.

Second, drug plans, whether they are free standing or embedded in an Advantage Plan, can and do change every year. What is covered one year, may not be covered in the formulary the next year, it may be at a different tier, the premium may change, the plan may disappear from your geographic region, etc. It is important that you at least check out the plans yearly during open enrollment - which takes place from mid-October to early December annually. The decision you make now, if you purchase a free standing drug plan, is only valid until December 31, 2017. Make the decision for the next 6 months based on what is the best plan for the drugs your husband is taking now. You can and should revisit this every year as the plans change and his drugs change. What a company charges or covers today, may be completely different in 2018 anyway, so thinking into the future about only drugs is of somewhat limited value right now anyway, particularly with the very expensive specialty drugs on the market as they are the drugs most likely to be impacted by changes in a plan's formulary from year to year.

The premium every month is only a small part of evaluating a free standing drug plan. Deductibles, what drug is subject to the deductible and what drug is not,, what tier a drug falls into on a specific plan's formulary, what drugs are on the formulary, specialty drugs, how the donut hole is managed for the drugs your husband is taking in a particular plan, and preferred pricing pharmacies are all part of the equation for finding the best free standing drug plan for the year.

If you buy an Advantage Plan, this "replaces" your Medicare all together and the insurance company offering the Advantage Plan becomes your insurer as to providers, deductibles, co-pays, out of pocket maximums, and drug coverage. It is all inclusive. Although Advantage Plans are less expensive in premiums every month, the out of pocket costs can become quite high for people who use extensive health care as to hospitalization, doctor visits, tests, etc. If you look at an Advantage Plan, be sure to look at their formularyas they can be even more limited than the stand alone prescription plans. Also, make sure the doctors that are important to your husband's care are part of the company's network of physicians.

As a general concept, we encourage individuals who are financially able to afford the higher monthly premium to purchase a Medicare Supplement Plan (Medigap Plan) to go along with their basic Medicare A & B and then purchase a free standing Part D prescription Plan. As a general rule, this provides the most comprehensive coverage for all aspects of a patient's health care, which is particularly important when you enter the system knowing you have a serious health problem. The most comprehensive Supplement is the F Supplement; which covers all deductibles and co-insurances that Medicare does not pay. All Medicare Supplement Plans of a certain letter are the same no matter what state you buy them in or what company sells them. The federal government regulates Supplement Plans. The only difference is in monthly premium, which can be based on zip code, gender, smoking, entry age and the company premium practices,assuming you buy during your initial enrollment period.

I could go on and on and I am sure I gave you FAR more information than you were looking for! processes should be the same.

By the way, Medicare.Gov is an excellent and very user friendly website. The Prescription Drug Plan section allows you to create your own drug profile and see all of the plans that are available in your zip code (Free Standing and Advantage Plans) and compare each of the plans to see which plan is best for you for that year. You can actually drill down to compare price, cost information by month, cost by drug, etc.

Good luck to your husband in his treatment going forward and in the wonderful world of Medicare!!

lovif said...
LSil: I actually work one day a week as a Medicare counselor for my local SHIP provider. SHIP is the State Health Insurance & Assistance Program - a federally funded free state counseling program that helps seniors understand Medicare, Medicare Advantage, Medicare Supplement (Gaps), Part D RX programs, and financial assistance programs for income eligible Medicare recipients. I strongly encourage you to find your local SHIP program and speak with one of their counselors. The decisions you make about Medicare at your initial enrollment are critical, particularly when you know going in that you have chronic and potentially serious and expensive health conditions. This service is free of charge and not affiliated with any insurance company, drug company, etc. It is important that you exercise the same due diligence in this decision making process that you exercise in your treatment process. Some of the information provided in the responses here is good general information; some is incorrect.

Thanks for that excellent post!

Great info!
We are in So Cal and my husband has a Part D plan through Humana. The cost is around $27 a month and when he was on Xtandi our out of pocket was about $2,380.00 in January, which quickly jumps you through all the tiers, and in February when the bill came our part was then about $435.00 a month. I believe the insurance was billed between $8500 to $9,000 for the drug.
Seeing that he is now having Jevtana in the treatment center, we are not paying that bill which I see is being billed for about $19,000.00 a treatment! Yikes!
Since he has gone through all the tiers so quickly, the remainder of his prescriptions for the year are very reasonable. I picked up his prednisone, 30 day supply, for $3.30 today.
Hope this helps!

lovif,
Thanks for the advice you've given already re Medicare. I'm wondering, being on the brink of needing to start lupron, if this is administered in the oncologist's office does it completely bypass the donut hole payment requirements of part D? Or do I have to pay full amount after passing the initial threshold?

Also, this may be asking more than you can answer, but I'm wondering, should I need expensive new drugs -- Zytiga, Provenge, etc, my current Medicare Advantage plan says I pay 25% after getting past the donut hole (within which I pay 100 %.). If I left the Advantage plan, are there original Medicare plus some supplement plan that would potentially cost me less to get the treatment I may need, or am I going to be on the hook for 25% of treatments that may cost thousands of dollars per month?
Jim

I forgot to mention in my above post that my husband also has a Medicare supplement plan (I believe it's an "F" plan) which costs about $226.00 a month. This covers his monthly Lupron shot given in the doctor's office and is paying 100% of what Medicare isn't paying for the Jevtana. He has had both plans, supplement and drug, since he went on Medicare 9 years ago and we have never had any out of pocket costs for doctor visits, scans or blood work. In all my research for drug coverage I haven't seen any plan that would give you drugs without needing to pay something.
lovif probably knows this info if there is one! What a wealth of knowledge that post was!!! Thank you!

The monthly penatly is a small amount, and applies only if you do not have existing drug coverage. So add up how much you would pay every month for a year, then compare that to what your "penalty" would be. Much of this depends on whether you are someone who has lots of medical problems and needs lots of expensive drugs, or if you are a relatively healthy person who presently uses few or even no prescription drugs and need only be concerned about what you may require in the future.

FWIW I am eligible for VA prescription coverage, which I have been told would spare me from the penalty.

RobLee, my husband is also eligible for VA drug coverage but when he went to the VA for his Xtandi, their oncologist board felt he wasn't in need of it at that time, so they wouldn't prescribe it for him. We also tried when he was on Zytiga and they weren't prescribing that at all at that time. Just wanted that thrown out there that just because you need it, you might not always be approved! No argument and nothing against the VA, just wanted to let you know our experience.

I'm also keeping the VA up my sleeve. I already get me EpiPens through VA for zero copay vs $350 per year under my Medicare Advantage plan. I'm not too worried about copay on Lupron, when it comes to that, though I remember there is someone on this board who gets his Lupron from the VA, even though he is under the care of an oncologist at Mass. General.