Medicare Drug Plans

els19

With the change period on the horizon I'm starting to think about drug plans. I have traditional Medicare and plan F for my supplement which I chose at the time because of my cancer background. My drug plan did well for the couple meds I'm on. But now with the recurrence things have definitely changed. Have any of you found Medicare drug plans that cover more? I'm especially interested in case the chemo is not effective and I have to move on to the next step. I've also been reading that many are on some type of maintenance medications. Can anyone list some of the names of these medication so I can search formularies? Thanks!

cmb

Medicare Plans

I just started Medicare and had to select Plan G since I was born a year too late for Plan F. They're basically the same plans, except that I have to pay the Part B deductible.

I haven't received any cancer treatment under Medicare so I can't say if another plan would be better. But I did post information about Medicare Advantage plans at https://csn.cancer.org/node/320249 that described a potential problem for cancer patients with these types of plans.

The Part D drug plans are trickier and, according to my sisters, change coverage often, even within a plan year. But at least you can change those plans every year without medical underwritiing.

 

oldbeauty

Good topic!

Because of the fact you have only a 1-time chance (at first eligibility) to get the best supplemental Medicare plan for your needs without medical underwriting (I agree with cmb that Plan G fits best), I would opt for original Medicare plus Plan G over any Medicare Advantage plan.  And, I agree with cmb that it is the drug plan, Part D, that can be the trickier choice.  You really have to look at the formularies, and do it every year, to find the most bang for your buck.  I've had 2 years of Medicare and 2 different Part D Plans.  The Part D premiums really went up this year, and formularies changed such that one year one of my drugs had no copay the first year, but this year it's quite expensive.  It's a generic plain vanilla type of drug.  Go figure!

As a recurrent UC patient who may be facing some kind of further treatment in 2021, I am stressign about this.  I expect to get a biopsy before the end of the year on the  slow-growing nodule in my lung.  If it's another recurrence, I hope to have it addressed with surgery and/or radiation and have no doubt Mediare and Plan G will cover it all.  But I know nothing about what chemo or maintenance drug my onco may recommend.  I will ask her at my November appointment so I can research formularies before selecting next year's Part D coverage.

I've not incurred any Medicare expense except for the annual deductible (negligible) for CTs, bloodwork and alternative treatments I didn't expect to be covered (oh, those crafty coding warriors ;>) !).  I'd love to hear any reassurances or horror stories from ladies who have undergone treatment after chemo with a different regimen than the typical frontline treatment.

Thanks for starting this thread.  Best wishes, Oldbeauty

els19

Medicare

I agree, Traditional Medicare with a supplement offers the best coverage for cancer patients. I was able to get Plan F which is no longer offered when I first enrolled.  Plan G is now the best supplement. But Drug plans are confusing. You really do have to check formularies every year for your prescriptions. Now that I'm having a recurrence I want to have some idea what to prepare for and what possible drugs I might be on next year. I plan on asking my doctor at the next appointment. 

Fridays Child

Plan D

Like some of you, I will be on regular Medicare and Part G as of next month.  I chose my Part D plan based on my current maintenance drug (Megace), but we looked up some of the potential drugs I might take if this stops working and let's just say no matter what the drug plan, they'd better find me some help!  If I go on Keytruda and Lenvima, the Lenvima is astronomically expensive.  Same with Letrozole and Affinitor - the Affinitor is very expensive as well. I'm told my cancer center has two full time employees whose job it is to make these within reach for their patients.  Didn't find any Part D plans where they weren't outlandish. I might need to rearrange my oncology appointments so that if there's going to be a change, I'll know it in the fall in time to select the appropriate plan.

Wish it didn't have to be so complex!  We have no idea what our treatment will be from one year to the next.

oldbeauty

Fridays Child said:

Plan D

Like some of you, I will be on regular Medicare and Part G as of next month.  I chose my Part D plan based on my current maintenance drug (Megace), but we looked up some of the potential drugs I might take if this stops working and let's just say no matter what the drug plan, they'd better find me some help!  If I go on Keytruda and Lenvima, the Lenvima is astronomically expensive.  Same with Letrozole and Affinitor - the Affinitor is very expensive as well. I'm told my cancer center has two full time employees whose job it is to make these within reach for their patients.  Didn't find any Part D plans where they weren't outlandish. I might need to rearrange my oncology appointments so that if there's going to be a change, I'll know it in the fall in time to select the appropriate plan.

Wish it didn't have to be so complex!  We have no idea what our treatment will be from one year to the next.

I share your concern

I need to research whether it makes a difference if certain of these drugs are infused at the cancer center inside the hospital. I remember back in 2017 when I had chemo it was all so confusing.  In the end, my only OOP was the high deductible we chose under the ACA.  We paid over $10,000 OOP but that was cushioned by the significant subsidy on premiums under the ACA.  It was very upseting to see each EOB come thru showing each visit to what I call the chemo lounge was billed out at retail for about $50 grand for bloodwork and infusion!.  Of course, the in-network discount ate up 99% of that but it still makes you think...what if I did not have insurance.  I am so happy to be Medicare age; the years of sweating thru government attempts to kill the ACA were horrible.

I see my onco in mid-November and plan to question her closely about likely therapies to identify which ones rely on Part D and which ones can be done under Medicare regardless of use of drugs.  Best wishes to all, Oldbeauty

MoeKay

CMS Publication on Coverage for Cancer Treatment Services

Oldbeauty, this CMS Publication may help.  See pages 4 and 6 for what is covered under Medicare Parts B and D.  I think drugs infused at the cancer center inside the hospital would come under Part B, unless you are an inpatient at the hospital at the time of the infusion (see Part A coverage on page 3):

https://www.medicare.gov/Pubs/pdf/11931-Cancer-Treatment-Services.pdf

oldbeauty

MoeKay said:

CMS Publication on Coverage for Cancer Treatment Services

Oldbeauty, this CMS Publication may help.  See pages 4 and 6 for what is covered under Medicare Parts B and D.  I think drugs infused at the cancer center inside the hospital would come under Part B, unless you are an inpatient at the hospital at the time of the infusion (see Part A coverage on page 3):

https://www.medicare.gov/Pubs/pdf/11931-Cancer-Treatment-Services.pdf

Thank you, MoeKay

I will study this.  It is what I would hope for.  I also am under the impression that some of our ladies take pills at home but I am not sure.  If I am in another recurrence,  and surgery/radiation is incomplete,  I figure they may want to hook me up again since I got 3 years of NED and obviously responded well to Carbo/Taxol.  One step at a time!  But thanks for the reference.  Best wishes, Oldbeauty.

Fridays Child

oldbeauty said:

Thank you, MoeKay

I will study this.  It is what I would hope for.  I also am under the impression that some of our ladies take pills at home but I am not sure.  If I am in another recurrence,  and surgery/radiation is incomplete,  I figure they may want to hook me up again since I got 3 years of NED and obviously responded well to Carbo/Taxol.  One step at a time!  But thanks for the reference.  Best wishes, Oldbeauty.

Infusion vs. pills

oldbeauty, what I was told is that, for example, if I were to take the Keytruda/Lenvima combination, the Keytruda would be an infusion done at the cancer center and thus would be covered under Part B.  The Lenvima is pills you take at home and they are very expensive unless they make arrangements with the drug company, which is apparently very common.

Letrozole and everolimus (Affinitor) are both pills you take at home.  Letrozole is inexpensive but the everolimus is very expensive.   I'm not sure but there may be a drug similar to everolimus that can be infused, which would then bring it under Part B.

Good luck and I hope you don't have to deal with any of them !

Fridays Child

MoeKay said:

CMS Publication on Coverage for Cancer Treatment Services

Oldbeauty, this CMS Publication may help.  See pages 4 and 6 for what is covered under Medicare Parts B and D.  I think drugs infused at the cancer center inside the hospital would come under Part B, unless you are an inpatient at the hospital at the time of the infusion (see Part A coverage on page 3):

https://www.medicare.gov/Pubs/pdf/11931-Cancer-Treatment-Services.pdf

Double post

Double post

Maxster

Questions

I currently have Medicare Advantage.  I took it out because I was so healthy until I wasn't and the premimum was negligible compared to my supplemental.  However, I have a big out of pocket maximum.  It has covered all my drugs and chemo (after out of pocket max) and I can go anywhere in the US.  I got a second opinion out of state.  Can one go back to a supplemental after choosing an Advantage plan?  I thought the supplementals were age related so I wonder if my premiums for that and a drug plan will cost more than my current plan with out of pocket.  Is there a way to just search on the Internet or do I need to go back to my insurance agent?

cmb

Maxster said:

Questions

I currently have Medicare Advantage.  I took it out because I was so healthy until I wasn't and the premimum was negligible compared to my supplemental.  However, I have a big out of pocket maximum.  It has covered all my drugs and chemo (after out of pocket max) and I can go anywhere in the US.  I got a second opinion out of state.  Can one go back to a supplemental after choosing an Advantage plan?  I thought the supplementals were age related so I wonder if my premiums for that and a drug plan will cost more than my current plan with out of pocket.  Is there a way to just search on the Internet or do I need to go back to my insurance agent?

Medicare Advantage to Medigap Switch

Once you've enrolled in a Medicare Advantage plan and are passed your "open enrollment" period (the initial signup period) there's no guarantee that an insurer will sell you a Medigap (supplement) plan. Insurers are allowed to consider a person's medical history before making a decision to sell you a policy then. See https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap

However, my sister was able to switch from her Medicare Advantage plan to a Medigap plan, even with preexisting conditions, when she moved from Arizona to Illinois since she was now out of the network for her Medicare Advantage plan. Oddly, although she's since moved back to Arizona, the Medigap plan she got in Illinois is still covering her medical expenses.

The supplement plans premiuns do increase based on age, but I don't know how those increases would compare to the Medicare Advantage out of pocket costs. You can try getting some idea of the costs at https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/buying-your-medigap-policy.

 

MAbound

Thank you for this thread!

I still have one year left to go before I'm eligible, but I am so thankful to those of you who are sharing your knowledge and experience on this topic. I hope that we keep this up for each other on an annual basis because things keep changing and the financial aspects of having a cancer diagnosis is such a big ongoing deal for all of us. I don't think that this topic will ever get old and it's one more thing that we can do to help each other get on down the road.

Molly110

Fridays Child said:

Infusion vs. pills

oldbeauty, what I was told is that, for example, if I were to take the Keytruda/Lenvima combination, the Keytruda would be an infusion done at the cancer center and thus would be covered under Part B.  The Lenvima is pills you take at home and they are very expensive unless they make arrangements with the drug company, which is apparently very common.

Letrozole and everolimus (Affinitor) are both pills you take at home.  Letrozole is inexpensive but the everolimus is very expensive.   I'm not sure but there may be a drug similar to everolimus that can be infused, which would then bring it under Part B.

Good luck and I hope you don't have to deal with any of them !

Infusion vs pills is a little

Infusion vs pills is a little complicated, because Part B does cover some outpatient chemo pills when the pill ingredient is the same that you would otherwise be getting in an infusion in the hospital or center, but there are some timing things and it can be tricky. So, of course, everyone should check and double check that their drugs are covered before choosing to go on Medicare or choosing a supplemental plan. Medicare.gov, the official Medicare site, is easy to navigate and written in lay language. There are also several good national nonprofit organizations that have great, easy to find and understand Medicare information.

I assumed it might be better for me to switch off private work insurance to Medicare when I was diagnosed right before the open enrollment period last year. But when I looked into the costs, I was better off staying with my work insurance, as Medicare premiums are linked to income for people who are still working, which I didn't know until I researched it.  I am fortunate that my work insurance is good, although I'm anxious this year about whether my organization will change insurance providers.

The last thing people with cancer or other serious illnesses or disabilities ought to have to worry about is how to pay for care. Thank God for Medicare and Medicaid, which -- while not perfect -- are at least a foundation for care.

els19

Maxster said:

Questions

I currently have Medicare Advantage.  I took it out because I was so healthy until I wasn't and the premimum was negligible compared to my supplemental.  However, I have a big out of pocket maximum.  It has covered all my drugs and chemo (after out of pocket max) and I can go anywhere in the US.  I got a second opinion out of state.  Can one go back to a supplemental after choosing an Advantage plan?  I thought the supplementals were age related so I wonder if my premiums for that and a drug plan will cost more than my current plan with out of pocket.  Is there a way to just search on the Internet or do I need to go back to my insurance agent?

Medigap plans

You can change from an advantage plan to traditonal Medicare and a medigap plan during the change period which is coming up next month. When you first sign up for Medicare they are not allowed to look at any  health history. But after that you can change but you might be subject to underwriting where they look at your health history and decide to insure you. One of the benefits of traditional Medicare and a Medigap plan is that you can go anywhere in the US to any doctor or care facility and as long as they accept Medicare you are covered. There are several MediGap plans and currently plan G provides the most coverage. But when you have Medicare and a MediGap plan you also need a Medicare Drug plan.

Maxster

Thank You

Thanks to all for the Medicare information.  I just received plan changes for 2021 and my out of pocket went down!  I've never seen that happen.  I think it might be easiest to call my agent but if pre-existing conditions can be taken into account I doubt I can get a Medigap plan.  I guess Medigap plans were not included in the Affordable Care Act pre-existing condition exclusion.  But even assuming I need to use all of my out of pocket, I still think it may be less than a Medigap plan. If travel ever resumes I'll just have to get travel insurance.  Thanks again.

els19

Medigap

I've known people who were able to change to a Medigap plan, Maxster. So, it might be worth checking into it and compare prices.

Forherself

els19 said:

Medigap

I've known people who were able to change to a Medigap plan, Maxster. So, it might be worth checking into it and compare prices.

We changed

From an Advantage plan to Medicare supplemental.  Our agent did this.  She switched us to AARP supplemental and then we were able to change to the Medigap plan without  checking pre existing conditions.  It seems like some kind of loophole, and I live in Washington State which may have something to do with it.   Once you have Medigap you can move to other Medigap plans which we did.

 

cmb

Article about Oral Cancer Drugs Costs Issues

There is an article in the Cancer Today magazine that talks about oral cancer drugs and their coverage though Medicare and Part D plans, as well as alternative funding sources.

See "Learning Medicare’s ABCDs" at

https://www.cancertodaymag.org/Pages/Fall2020/Learning-Medicares-ABCDs.aspx

cmb

Forherself said:

We changed

From an Advantage plan to Medicare supplemental.  Our agent did this.  She switched us to AARP supplemental and then we were able to change to the Medigap plan without  checking pre existing conditions.  It seems like some kind of loophole, and I live in Washington State which may have something to do with it.   Once you have Medigap you can move to other Medigap plans which we did.

 

Guaranteed Issue Right for Medicare Supplement (Medigap) Plans

This page from the Medicate.gov site explains when you are guaranteed the right to buy a Medigap plan even with pre-existing conditions and without increased premium costs.

https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights

But as Forherself noted, some states may offer more options. The Medicare website above lists the contact information for SHIP, which can help with the particulars in a specific state.

oldbeauty

cmb said:

Article about Oral Cancer Drugs Costs Issues

There is an article in the Cancer Today magazine that talks about oral cancer drugs and their coverage though Medicare and Part D plans, as well as alternative funding sources.

See "Learning Medicare’s ABCDs" at

https://www.cancertodaymag.org/Pages/Fall2020/Learning-Medicares-ABCDs.aspx

Wonderful!

Thanks, cmb.  You are the greatest!  Best wishes, Oldbeauty