Confused about Insurance/Medicare

Hello Mel - Usually your BCBS Medicare Advantage plan will have Part D plan contained within the plan that also coves Part A and Part B Expenses. Medicare Advantage plans are called Part C plans supplied totally by insurance companies and cover Part A, B, & usually D.

My wife's school district offered a BCBS Medicare Advantage Plan for retirees who qualified and it was quite good, mainly the drug part, so I would think your plan will give you the best Orgovyx coverage possible. It was also very expensive due to this better drug coverage.

You should be able to contact the school benefits group and BCBS directly to get the answer. A "Group" Advantage plan can be better than anything you can obtain on your own. You probably do not need to do anything since you would have to probably quit your plan to go in any other direction.

Part D drug evaluation is a little tricky given the complexity of Medicare. There is a deductible, regular insurance, donut hole and catastrophic coverage ranges so the math changes as your expenses go up.

A number of teacher retirement plans negotiate an advantage plan specifically for there retirees that have lower out of pocket expenses be cause the retirement plan is contributing a premium ($$$) each month. You will not get as good of plan on your own.

Prescription medications in an advantage plan can be denied and you can be required to try a less costly medication first.

If you opt for Eligard or Lupron, the medication is a injectable and is covered by your part B and you wont be paying $12,000 a year.

Mel,
Off topic from the thread, but I'm wondering why Dr. Lam is so keen on Orgavyx?

Thanks for all the responses. Dr. Lam just pushed the convenience (pill a day, sans shots) and works quicker both ways (start/stop). From my reading, MUCH less chance of heart disease and it might be more effective with slightly less SE.

Mel

I retire in August. Current prescription plan is with CVS Caremark. $9k/mo for Humira (a biologic) for my Ucerative colitis.

I’ve yet to pay anything for that drug. There was an issue one time when my prescription carrier changed. I called Abbot (who makes Humira) and spoke with them about it. They had some sort of “special deal”. They sent the med for free and worked it out with the insurance company themselves. They’re good at this. I’m unconvinced the insurance companies pay sticker price for these drugs. The companies want people taking them and it appears as if they’ll take whatever they can get to make that happen.

Call the maker of the drug and tell them you just can’t afford it or the copay. See what they say.

When it comes to PSA scores and co-pays, zero is my favorite number.

(I also hope it is the number of runs that Clayton Kershaw gives up tonight...)

FYI - My wife received her first month of Ibrance free from University then she paid $2800 (25%) for the second month. Then her application to Pfizer was approved and has been free, delivered directly from Pfizer, since then. We had to submit some additional paperwork (front two pages of last 1040) as I recall and have to reapply every year.

I got the feeling that the first month is a trial to see if one will tolerate the expensive drug before full scale assault on your pocketbook and the insurance company. Stay after whatever they require to get your drug subsidized under Medicare rules. Free is best so go for that first. Go to the manufacturer’s website and see what they offer so you are informed. Hopefully you can find someone in your doctor’s office to help with this. The university had pharmacy people help us apply.