zytiga/xtandi cost

Well, trying to check further.
Apparently, OPTUMRX is my regular insurance pharmacy, but this drug goes to their specialty pharmacy (Briovarx). According to Optum,if I fill it via the specialty pharmacy the cost drops to $40 per month!!! That's one heckuva difference. Yet when I call Briovarx, the person seems confused and they are unable to confirm it. I hate dealing with medical insurance people.

Mel

Mel, when Dr Lam put me on Zytiga their office ran down the insurance payments for me. I think my co-pay was also about $40/mo and it was filled by a speciality pharmacy, as well. However, I was not on Medicare.

Yeah, the "Special Pharmacy" huge price cut nonsense, god knows what goes on backstage between the drug manufacturer, the distributor, the insurance company, the special pharmacy and the doctor who wrote the script...Lots of things in motion here...What a system..Here we have a fairly common cancer drug with a VERY high list price ($12,000 / month) but nobody pays that. In fact, virtually every patient who receives it pays a different price ! The more you squirm and squawk the cheaper it gets.......

Mel, I think it would be best if you contact your plan to nail down the costs. Zytiga is an expensive drug but most plans have an initial high cost and then the cost becomes much more affordable. With medicare advantage there is a deductible stage, the donut hole, and then, catastrophic coverage. I pay about $5,000 at the beginning of the year and then the cost drops after that.

I have been going through this for the last three years and each year I have to study the plans carefully to find the plan that will give me the best prescription drug coverage.
I looked at the plan you mentioned BCBSM Medicare Advantage plan. Just to make sure is this a Blue Cross Medical Advantage Plan? If so, they do provide prescription coverage and I found that Zytiga was on their formulary. The plan has three stages of prescription coverage as follows: 1) Initial coverage stage;2)Coverage Gap, and; 3) Catastrophic Coverage. Each prescription is categorized in tiers and Zytiga falls into tier 5 category. In the initial stage, you will pay 33% of the retail cost of Zytiga, up and until you reach a maximum of $3,750. You will then move into the coverage gap stage and will pay up to 44% percent of the cost, up to and including $5,000.00. This is your maximum out of pocket expense during the initial stage and coverage gap stage. Once you spend $5,000.00 you will move into catastrophic coverage and your monthly cost of Zytiga will be either an $8.35 copay or 5% of the cost, whichever is greater. It also looks like you have an additional PDP called Optum RX. I am not familiar with this plan so maybe you can shed some light on it. If it is additional coverage then your Medicare Advantage plan would pay first and then Optum RX would pay next. If this is the case then you may have additional savings.
I think that the PDP plans are complex and often time the representatives on the phone are no fully aware of how the drug plans work and it causes a lot of anxiety with me. But if it gets too expensive for me I am just going to let nature take its course and hope for the best. I hope this helps a little.

Post Edited (Almost a 10) : 10/22/2018 11:26:10 AM (GMT-6)

Almost:

OptumRX is my PDP. But they said that Zytiga goes through Briava, their specialty drug plan/company, and it would be $40/month. Now I wish Briava would say that!! They do not quote me a price because I have to fill out a new patient form, which I cannot do until Zytiga is prescribed. Catch 22. But I am going to call again, because the person I spoke to just did not seem knowledgeable.

My plan is BCBSM PPO and it is a MediCare Advantage Plan.
I'm actually having a hard time finding the formulary online, but I might have it in the ton of written materials I have.

Mel

Almost:

Not sure if that is the applicable formulary -- it probably is.

My telephone appt. with Dr. Lam has been changed until Friday.
Still awaiting PSMA scan results

Mel

Tufts Health Plan pays CVS Specialty -$9,383.64 per month. Copay is $50.

Mike

Compiler,

I am retired from the pharmacy benefit industry. I think you have correctly identified the complexity of pharmacy insurance. There are many different policies as well as unique plan designs. I would start with your prescribing physician. He/she can send a letter to your insurance company to determine if the potential meds will be covered and to which extent. Many insurers will require a PA (prior authorization) from your physician for coverage. A PA is basically a "speed bump" to protect against over prescribing of expensive drugs. OptumRx is a middle man in this equation. They must comply with the payer/insurance company's benefit design. OptumRx has a group within the specialty business that is called "benefit investigation" that will also determine your benefit. OptumRx wants to fill your prescription under insurance because they will get paid. I have no idea what they will pay but starting with your physician is your best bet. Good Luck.

Pharmaceutical companies will support you if your income is low. Otherwise forgettabout it.

Mel, I presume (hoping) that's good news if it's just Casodex and Lupron for now.

Mel, that does sound good on balance! Good luck with your RO appointment.