Medicare Advantage and Step Therapy for Part B Drugs

cmb · August 2019

I'm looking forward to signing up for Medicare next year as I reach 65. Since I was born one year too late to get a Plan F Medicare supplement policy, I expect to select a Plan G supplement policy. While I prefer the flexibility of a Medicare supplement plan, others also nearing 65 may also be considering a Medicare Advantage plan.

There was a recent news article that explained a potential problem with a new Medicare Advantage regulation for those cancer patients whose drug treatment doesn't follow the "approved steps."

https://www.sacbee.com/news/state/california/article232478212.html

There is also a 2018 Fact Sheet on CMS's website that explains what step therapy is and how it applies to "Part B" drugs – those commonly given to cancer patients.

https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-prior-authorization-and-step-therapy-part-b-drugs

CMS finalized its regulations regarding Medicare Advantage and Step Therapy for Part B Drugs in May 2019.

https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-and-part-d-drug-pricing-final-rule-cms-4180-f

Just one more wrinkle in health insurance for those debating whether to get a Medicare Advantage plan or a Medicare supplement policy.

TeddyandBears_Mom · August 2019

Thanks for sharing. I'm 3

Thanks for sharing. I'm 3 years away from having to figure this out myself. So much information to learn.

Love and Hugs,

Cindi

CheeseQueen57 · August 2019

Medicare Advantage

I was advised that the Medicare Advantage plans, although appear attractive with their enhanced benefits, are generally not a good idea because of their restrictive networks and other restrictions. I’ll be sticking with traditional Medicare with the F plan.

EZLiving66 · August 2019

We went with the Humana

We went with the Humana Medicare Advantage plan. We have a huge network of providers in the Tampa Bay area but what we're finding is lack of quality dentists. I've never had to deal with Medicare for my cancer but I have enough horror stories before I was 65 with this step-therapy. Same with our son who has T1 diabetes - OMG, the hours I spent on the phone trying to get him the medication his doctor prescribed! I think as medication and treatment plans' costs rise, there will be more and more insurance companies using this step-therapy.

Love,

Eldri

Armywife · August 2019

Oh dear

This makes my head spin. I don't seem to have the concentration skills I used to have - I do have five more years to sort it out, but I dread having to figure all this out.

BluebirdOne · August 2019

Armywife said:
Oh dear
This makes my head spin. I don't seem to have the concentration skills I used to have - I do have five more years to sort it out, but I dread having to figure all this out.

Medicare is not that difficult to understand.

I think what most people don't understand is that being on Medicare with a supplemental plan and a drug plan is EXPENSIVE. $162.00 a month taken out of my Social Security check for Medicare Medical Insurance and a presecription drug plan. I have an additional monthly $150 Medicare Supplemental Plan G. Plus the annual medicare deductible of $185. So my annual cost is $3929.00 I am 68. This does not include any dental or vision care. So we budget about $5000 year for my medical. I also have very small copays on some of my medication. For me, the good news was that Medicare paid every dime of my medicals bills from pre-diagnosis to surgery to checkups and scans. I think we might have had a bill of $36.00 for something that was not covered. But I was Stage 1a, with no complications. It will be interesting to see what happens if I do recurr.

The supplemental plans are tricky. Luckily the plans are standardized from insurance company to insurance company so that everyone's Plan G is the same. We did not like the Medicare Advantage Plan, but everyone can decide what is best for themselves. Medicare.gov has a terrific website that explains things in plain English to give you a head start on sorting things out. We still have to pick out a plan for my husband every year and it is way more complicated (trying to figure out how the insurance company is going to screw you by denying coverage) than Medicare and the medigap plan.

Denise

CheeseQueen57 · August 2019

BluebirdOne said:
Medicare is not that difficult to understand.
I think what most people don't understand is that being on Medicare with a supplemental plan and a drug plan is EXPENSIVE. $162.00 a month taken out of my Social Security check for Medicare Medical Insurance and a presecription drug plan. I have an additional monthly $150 Medicare Supplemental Plan G. Plus the annual medicare deductible of $185. So my annual cost is $3929.00 I am 68. This does not include any dental or vision care. So we budget about $5000 year for my medical. I also have very small copays on some of my medication. For me, the good news was that Medicare paid every dime of my medicals bills from pre-diagnosis to surgery to checkups and scans. I think we might have had a bill of $36.00 for something that was not covered. But I was Stage 1a, with no complications. It will be interesting to see what happens if I do recurr.

The supplemental plans are tricky. Luckily the plans are standardized from insurance company to insurance company so that everyone's Plan G is the same. We did not like the Medicare Advantage Plan, but everyone can decide what is best for themselves. Medicare.gov has a terrific website that explains things in plain English to give you a head start on sorting things out. We still have to pick out a plan for my husband every year and it is way more complicated (trying to figure out how the insurance company is going to screw you by denying coverage) than Medicare and the medigap plan.

Denise

Medicare Part D is the complicated part

Trying to figure each one‘s formulary, copays, deductibles, patient satisfaction ratings and what it will cost you in the donut hole I found extremely confusing. In the end, I had no choice cause of my former employer. Fortunately donut hole goes away next year because the cost of me Eliquis went from $105 for 90 days to $350 for 90 days since I hit the donut hole in June.

MAbound · August 2019

Oy!

I'm sure glad you guys post about this stuff. My husband is figuring out this stuff for himself now and we've been taking into account what's been shared here. It's not always just about the cancer! Thanks!

BluebirdOne · August 2019

CheeseQueen57 said:
Medicare Part D is the complicated part
Trying to figure each one‘s formulary, copays, deductibles, patient satisfaction ratings and what it will cost you in the donut hole I found extremely confusing. In the end, I had no choice cause of my former employer. Fortunately donut hole goes away next year because the cost of me Eliquis went from $105 for 90 days to $350 for 90 days since I hit the donut hole in June.

I never had to deal with expensive medications

just simple generics even though I have high blood pressure, high cholesterol, hypothryroidism, and pretty bad osteoarthritis. So people need to take into consideration their ongoing medical needs like Type 1 diabetes, etc., in order to select the best plan for them. Medicare.gov has a pretty good page that deals with it. I would advise a year before you are eligible to start becoming familiar with what is offered so you are making informed decisions. https://www.medicare.gov/find-a-plan/questions/home.aspx

The big difference for me was that I was already on Medicare when I was diagnosed, and that I was Stage 1a, with surgery, chemo and brachy, all were 100% covered for me. I can't speak for anyone who has more advanced cancer, not on Medicare, or who has expensive pharmacy needs. Like anything, education about your options always helped me.

Denise

mamlicsw · August 2019

BluebirdOne said:
I never had to deal with expensive medications
just simple generics even though I have high blood pressure, high cholesterol, hypothryroidism, and pretty bad osteoarthritis. So people need to take into consideration their ongoing medical needs like Type 1 diabetes, etc., in order to select the best plan for them. Medicare.gov has a pretty good page that deals with it. I would advise a year before you are eligible to start becoming familiar with what is offered so you are making informed decisions. https://www.medicare.gov/find-a-plan/questions/home.aspx

The big difference for me was that I was already on Medicare when I was diagnosed, and that I was Stage 1a, with surgery, chemo and brachy, all were 100% covered for me. I can't speak for anyone who has more advanced cancer, not on Medicare, or who has expensive pharmacy needs. Like anything, education about your options always helped me.

Denise

I just ran into a surprise regarding my Medicare Advantage Plan.

I live in Massachusetts and have Harvard Pilgrim's Medicare Advantag plan called STRIDE. I had Harvard Pilgrim as an employee pre Medicare and was pleased with it. I found after receiving a bill for $640 from my Cancer Center that 15% of immunotherapy and radiation is not covered. I can afford it, but many people can't. I was surprised, disappointed, and angry. I'll be looking into other options as I don't feel this is what an insurance company should do. I've only had 2 cycles so I assume I will be getting more charges. I expressed my displeasure and let them know this would cause me to look at other plans. I'm wondering if this has happened with others on this Board. I also wonder who is happy with their plan. I will have surgery, chemo, and 6 brachytherapy appointments for my Stage 1a, Grade 3 cancer. thanks to anyone who is able to respond. Mary Ann

cmb · August 2019

mamlicsw said:
I just ran into a surprise regarding my Medicare Advantage Plan.
I live in Massachusetts and have Harvard Pilgrim's Medicare Advantag plan called STRIDE. I had Harvard Pilgrim as an employee pre Medicare and was pleased with it. I found after receiving a bill for $640 from my Cancer Center that 15% of immunotherapy and radiation is not covered. I can afford it, but many people can't. I was surprised, disappointed, and angry. I'll be looking into other options as I don't feel this is what an insurance company should do. I've only had 2 cycles so I assume I will be getting more charges. I expressed my displeasure and let them know this would cause me to look at other plans. I'm wondering if this has happened with others on this Board. I also wonder who is happy with their plan. I will have surgery, chemo, and 6 brachytherapy appointments for my Stage 1a, Grade 3 cancer. thanks to anyone who is able to respond. Mary Ann

Switching Medicare Plans

Since I'm not on Medicare yet, I can't say how they would have covered my chemotherapies. On my current insurance I only had to pay the deductible and out-of pocket cost each year.

But I will say that my sisters, who each have had some pretty extensive, although not cancer-related, medical issues have not had to pay anything extra beyond the fees of their Medicare Plan F supplement policies. Hopefully some of the members on this board will chime in with their experiences,

Depending upon how long you've had your Medicare Advantage plan, you may be subject to medical underwriting if you want to switch plans. This means an insurer can refuse to issue you a policy because of a pre-existing health condition.

But there are some exceptions to this: For example, during the 12 months of first enrolling in Medicare Advantage coverage, you can dis-enroll. Then you can enroll in a Medicare Supplement instead, this is called the Medicare Advantage trial period.

You can read about the different circumstances when you can switch plans without medical underwriting (called "guaranteed issue rights") at the following site:

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

Medicare Advantage and Step Therapy for Part B Drugs

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