My three-month sprint to full Medicare coverage

[target2019]

I've read many Medicare threads here during the past 13 years.
In four months (July 1, 2022) I will say goodbye to our group insurance coverage that has been amazingly great for over 35 years. We are in the state of New Jersey.

I signed up for Part A when I turned 65. Now I have the decision of taking the next steps. Please tell me what to do! I say that half-jokingly, as I have absorbed a lot of knowledge, watched many videos (like Boomerbenefits), and followed this thread https://www.early-retirement.org/forums/f38/medigap-plans-to-rule-out-93148.html

I want to make sure I do not stumble. I find myself forgetting more key points each day. So I want coverage that is simple and easy to understand, and I'd like to know how I make payments for each part of the following.

1. I believe at this time my best option is Medigap (and not Advantage). I have been on the Medicare site several times, so I think this is a simple decision, just sign up for Part B coverage. The best site I've found to describe coverage available to me in NJ is https://www.aarpmedicareplans.com/
   
2. Next is a choice for Supplement, like Plan G or something else? That is somewhat of a mystery to me, even now. Yes, I've read the Medicare booklet, it's just confusing for me to put together actions to make good decisions. I'll read it again for good measure, though.
   
3. For a drug plan Part D, I have entered my prescriptions on the Medicare site, and found that 12 of 14 are covered. Of the choices, CVS, Rite-aid and mail-order, the yearly cost for the 12 common drugs is not a concern to me ($1250 per year). They are all very close. But one drug not covered (Balversa) adds about $1,000 per month out of pocket. With our group insurance now, it is $5.00 monthly. Big difference, so I need to understand more about that, and what do others with similar burden do?
   
4. Dental and Eye coverage seems simple. That seems to be part of Plan G. Is it worth looking for other options?

Am I on a path that sounds not-too-crazy, at least up to this point? What am I mis-interpreting or missing completely?

With stage 4 urothelial cancer I have a shorter shelf-life than some. While everyone was enjoying the arrival of Covid in early 2020, I had several hospital procedures, and then chemo-therapy. Had good results with that. Then it was on to immuno-therapy (didn't work), and then Balversa (works for about 18 months). At best, I'll be done with Balversa within a year, as cancer can figure that out eventually. So, at that point I'd go back in the chair for chemo-therapy.

That paragraph is just to give some context. Of course I can't predict anything, really. Just setting a range of probable outcomes to help me with the Medicare choices and decision making.

Thank you for each and every response.

 

[VanWinkle]

With your known expenses and health concerns, I would definitely go for plan G supplement, the best drug plan for your current regiment, and you can likely handle dental and eye coverage OOP. The Plan G and Drug plan can both be deducted from your SS payment, or auto pay from any checking/savings account. I wish you well on the health concerns and it sounds like you have the right attitude about the future.

VW

 

[omni550]

But one drug not covered (Balversa) adds about $1,000 per month out of pocket. With our group insurance now, it is $5.00 monthly. Big difference, so I need to understand more about that, and what do others with similar burden do?

target2019,

A friend on Medicare recently told me that she contacted the pharmaceutical company which produces an expensive Rx drug she was taking. Apparently they have a program that 'comps' drugs for folks with income less than $71,000, and she has been getting that specific drug for free ever since.

I don't know any of the particulars but it sounds like the pharmaceutical company has a special office that handles these requests. Perhaps start with Customer Service?

omni

 

[Sue J]

Dental and vision coverage are not part of Part B or a supplement Part G. Only Medicare Advantage plans include dental and vision.

If you haven't gotten the Shingrix vaccinations yet, get that done before Medicare. Many pre medicare plans cover those at 100% where medicare covers that in Part B after the deductible is met.

 

[target2019]

Dental and vision coverage are not part of Part B or a supplement Part G. Only Medicare Advantage plans include dental and vision.

If you haven't gotten the Shingrix vaccinations yet, get that done before Medicare. Many pre medicare plans cover those at 100% where medicare covers that in Part B after the deductible is met.

Thank you for your help. I see that the dental benefits of a particular Plan G read like this:

Dental Discount
Receive discounts for dental services from in-network dentists through Dentegra:
In-network discounts generally average 30-40%† off of contracted rates nationally for a range of dental services, including cleanings, exams, fillings and crowns.
Access to 30K in-network general dentists and specialists at 90K locations nationwide.
No waiting periods, deductibles, or annual maximums.
The Dentegra dental discount is not insurance.

So, it is not insurance coverage, as you said. We are probably going with a Delta Dental plan of some kind.

The tip about Shingrix vaccine is appreciated.

 

[target2019]

With your known expenses and health concerns, I would definitely go for plan G supplement, the best drug plan for your current regiment, and you can likely handle dental and eye coverage OOP. The Plan G and Drug plan can both be deducted from your SS payment, or auto pay from any checking/savings account. I wish you well on the health concerns and it sounds like you have the right attitude about the future.

VW

Thank you for the response. I appreciate this very much.

 

[target2019]

target2019,

A friend on Medicare recently told me that she contacted the pharmaceutical company which produces an expensive Rx drug she was taking. Apparently they have a program that 'comps' drugs for folks with income less than $71,000, and she has been getting that specific drug for free ever since.

I don't know any of the particulars but it sounds like the pharmaceutical company has a special office that handles these requests. Perhaps start with Customer Service?

omni

Thanks, Omni. I currently have an agreement with the drug manufacturer. It is for 25K per year (when you have commercial or private insurance only), but is not applicable when you have gov't insurance. I confimed with the program exactly what that means. What they have on their site is a page to guide you to other resources: https://www.janssencarepath.com/patient/balversa/cost-support

I will look into all of those, but income level will probably exclude us/me from most, if not all of those programs. Of course I have to do the leg work and find out for myself.

In my specific case, our insurance coverage has actually paid for almost all of the cost of each prescription. It is dispensed by the hospital pharmacy, who has a driver bring it to me. This is what current insurance says for one prescription (30-day supply):

Billed by Pharmacy $23,500
Health Plan Paid $23,425
My Cost $75.00

That is interesting. At first I thought the agreement paid $75.00, but the drug company program coordinator told me that the pharmacy puts in a claim for $75.00, but then rescinds it!

I don't think I'll ever really understand what's going on there.

As for what happens in a few months, Medicare tells me that this drug is not covered by Part D, and the yearly cost out-of-pocket would be $14,100. This is definitely an area I'll continue to read about. I don't think this is the kind of drug where I can get a Rx and mail it to Canada. I'm sayign that tongue-in-cheek.

What I've found is that the drug cost is somewhat mysterious, as this drug makes its way from manufacturer to distributor to pharmacy to me. I'm expecting a promised call from the financial team of the hospital, to explain things a little better, and hopefully nail down costs based on specific Part D supplier.

 

[Bamaman]

My wife has had and will be having a few procedures. We switched to Plan F to Plan G in the middle of the year because she needed an electric wheelchair and I needed a new insulin pump. These are Part B items, and Plan G doesn't have the 20% Co-pay's.

But you might want to check if Part G covers pre-existing illnesses. I was thinking it asked me if I was in end stage renal failure--which I'm not.

I suggest you talk to a health insurance professional about your specific situation.

 

[harllee]

My DH takes a very expensive medication (Humira) and if he uses his Medicare Part D coverage he goes into the donut hole immediately. He has been able to get free Humira through a foundation set up by the drug manufacturer, he gets it even though he is on Medicare. I recommend checking with your drug manufacturer on that. Unfortunately for us he can not longer get the Humira help because our income is now too high --the maximum income is 86,000 per year.

 

[wdwwildbill]

My DH takes a very expensive medication (Humira) and if he uses his Medicare Part D coverage he goes into the donut hole immediately. He has been able to get free Humira through a foundation set up by the drug manufacturer, he gets it even though he is on Medicare. I recommend checking with your drug manufacturer on that. Unfortunately for us he can not longer get the Humira help because our income is now too high --the maximum income is 86,000 per year.

Harlee, I am close months away from medicare and I too take Humira but can't afford it once I get off commercial insurance. Any ifo on that foundation would help as I have not been able to find anything Tks WDW

There must be another work around for these super priced drugs !!!!

 

[harllee]

Harlee, I am close months away from medicare and I too take Humira but can't afford it once I get off commercial insurance. Any ifo on that foundation would help as I have not been able to find anything Tks WDW

There must be another work around for these super priced drugs !!!!

It is the AbbieV Foundation. DH's doctor told him about it, it is for people on Medicare. They have a website. There is an application that you and your doctor fill out and you have to reapply annually. They send you 3 months of Humira at a time. The tricky thing is the income limit of $86,000 per year for the entire household. You have to send them a copy of your income tax return. DH has qualified for 6 years, it has taken some work to keep our income under that amount. I went on SS this year at age 70 this year and we will no longer qualify.

 

[wdwwildbill]

It is the AbbieV Foundation. DH's doctor told him about it, it is for people on Medicare. They have a website. There is an application that you and your doctor fill out and you have to reapply annually. They send you 3 months of Humira at a time. The tricky thing is the income limit of $86,000 per year for the entire household. You have to send them a copy of your income tax return. DH has qualified for 6 years, it has taken some work to keep our income under that amount. I went on SS this year at age 70 this year and we will no longer qualify.

Thank you so much for this info. That limit may be tricky for me as well as DW and I are still slaving away for another year or so. Maybe generic around the corner but may still be pricey !! There are so many drugs with super high cost !!

 

[target2019]

Through the Part D Looking Glass

Here is my current direction on Part D stuff. What a crazy world!

I used the Medicare site a few times, entered my current line-up of drugs, and found that the chemo drug is simply not covered by any of the plans. A rough estimate is that the drug will cost $1,000 per month. This did not change much, no matter the plan. So I went with the cheapest plan, SilverScript.

After a week or two I got notice that Medicare told Aetna that I have no current drug coverage, and therefore Aetna will charge me more per month, up from $7 to some other number never mentioned. So I had to call in, and it took 30-60 minutes conversing with a very-difficult-to-understand CSR. Eventually I was able to give her some detail, like maybe it's in my spouse's name, LOL.

Then waited another week and got the big bill for $7.00 for two months. So, I have coverage. Last night I had a chuckle as spouse opened her welcome letter, and found out that she has had no drug coverage for the past 39 years. Well of course she does and now she has to call in and provide a legal voice attestation that she is covered.


Now for the really fun part. I called the hospital pharmacy with my plan ID, and received resistance that the only way to price the drug is to submit the order. Of course I know that is bs, based on previous call. So eventually she gives in and enters my new info, and lets me know my first co-pay will be $3,229.98. That is quite a distance from my current co-pay of $5. Something tells me we are not in Kansas any more!

Again, I persisted, and she let me know that the manufacturer special co-pay card will no longer work (which I already knew from several calls to the manufacturer). Then I went on hold as she conversed with a member of the FInancial Team. After 10 minutes or so she returned with the news that I can send them our tax return, and they will see what assistance I can get from various foundations. Again, old news, as a previous call to the Financial Team gave me all of that info. Between you and me I think it is unlikely that I will qualify for any assistance, but I will try that.

Meanwhile, it occured to me that the hospital pharmacy is way out there, not preferred or anything even close. So my next step is to get confirmation of the cost from CVS, meaning another call or two and maybe a visit to pharmacy. Hopefully the cost will be $1,000 as the Medicare and Aetna site told me.

Now, I think many would be dis-heartened, but I did get a smaller victory, as I learned that on 6/28 I can get one more refill, billed to the plan now in effect (not SilverScript), for $5.00.

And just think, I have not even discussed the G and B applications, not experienced the joy of living at this time, and feeling like a rat in some mad government/private experiment.

 

[REWahoo]

I have heard a number of times that chemo drugs are covered under Medicare Part B, not under Part D drug coverage. Might be worth looking into.

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

 

[target2019]

I have heard a number of times that chemo drugs are covered under Medicare Part B, not under Part D drug coverage. Might be worth looking into.

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

Thanks. I should have been clearer in the previous post (can't edit now).

- 1st phase of treatment was chemo in the traditional sense. You sit in a chair and get intravenous "stuff." AFAIK this is Part B now. Or it will be down the road.

- 2nd phase of treatment is a pill you take daily or on some other schedule. I am in this phase. This comes under Part D now. Or it will after June 30...

Up until the end of this month all charges went through private insurance, and that is a black box that worked well for me.

That's a good overview pdf to link, BTW, so thanks for posting. In it is mentioned, "Some oral chemotherapy treatments" are covered under Part B. I'll ask the center if they can try Part B submission.

Here are two other on-going discussions for reference:

https://www.early-retirement.org/forums/f38/mark-cuban-launches-prescription-drug-site-112747.html

https://www.early-retirement.org/forums/f38/where-does-medicare-fall-short-114320.html

 

[bmcgonig]

This is something new I just came across. Mark Cuban has started up a low markup online pharmacy. Might be useful to you or the rest of us

https://twitter.com/x/status/1538239670131298305

 

[Montecfo]

There is free counseling available for those approaching Medicare. They can do analysis based upon your usage and help you figure out which plan or plans to take.

it is under the SHIP program (State Health Insurance Assistance Program).

My sister in law used it and was very pleased. I will be using my state's version soon.

 

[target2019]

I'm now more than three months into Medicare. It's the system we have, right?

A positive development is that the immuno drug I take is a hot potato. Maybe that is due to recent legislation, but I really don't know. This drug is not on the list of the first wave of changes.

The big pharm company (not the little one, Lol) called me and welcomed me to their patient assistance program, on a trial basis (2 months provided, then they may examine income, total medical costs paird by me). This really was a surprise, as the hospital pharmacy I use told me I did not qualify for anything. The rep was genuinely a nice guy, and made me feel ok, never mentioning the cost or what the state of affairs is.

The backstory is that I take an immuno drug that has arrested the development of tumors. The cost went from $5 to an anticipated $3200 monthly after group insurance expired (spouse retired). The estimated Part D cost on Medicare site for my plan and this drug was $1,000 monthly before signup. Now, on the provider's site it is $3200, just like the hospital pharmacy.

There are several other twists to this experience with regard to what happens with Medicare billing, but I'll stop there.

 

[RetMD21]

Hope you are feeling well. The part D noncoverage of erdafitinib is unfortunate.

 

[braumeister]

Hope you are feeling well. The part D noncoverage of erdafitinib is unfortunate.

Drug coverage (or noncoverage) is not just unfortunate, but also mysterious. I don't think most of us fully understand it.

My DW takes a daily $500 pill ($15K per month), which boggles my mind. She is enrolled in a clinical trial, so the manufacturer provides it at no cost, but good grief, how can this be possible? If we had to pay for it, our drug plan would cover nearly all of it, but how can other people deal with this? As I said, just a mystery to me.

 

[harllee]

Drug coverage is definitely a mess now but it use to be so much worse. When my elderly mother went on Medicare in 1998 drugs were not covered under Medicare at all. In fact back then hardly any health insurance policies had good drug coverage. MY DH worked for a large corporation in the 1990s that had a "good" group health policy that only had $1000 of drug coverage (my DH would go through that in the first few months) and only a million of lifetime coverage.

 

[target2019]

Hope you are feeling well. The part D noncoverage of erdafitinib is unfortunate.

Thank you. I am feeling well, and chipper enough to travel to Europe again this year. We did same last year and had a tremendous time.

Now that I'm knee deep into Medicare and insurance things, I realize how important a yearly cap on drugs will be in the future. However, in the back of my mind I'm still suspicious.

I appreciate your post very much. Have a great one!

 

[target2019]

Drug coverage (or noncoverage) is not just unfortunate, but also mysterious. I don't think most of us fully understand it.

My DW takes a daily $500 pill ($15K per month), which boggles my mind. She is enrolled in a clinical trial, so the manufacturer provides it at no cost, but good grief, how can this be possible? If we had to pay for it, our drug plan would cover nearly all of it, but how can other people deal with this? As I said, just a mystery to me.

You have my empathy. My 2-a-day erdafitinib works out to $3200 monthly (in the future perhaps), or $80 per pill. Through the process we found that reducing the days each month did not change the scans, so less is as good as more. Even better, I get to take an entire week off, saving on cost, and gives me time to recover from side effects.

Without the adjustments I would require 60 pills each month, for $4,800 monthly.

But wait! There is another price, and that is what the manufacturer bills the pharmacy or hospital, and that is on the order of $1,000 monthly. However, I assume that is negotiated down.

So there is radiation, surgery, chemo, targeted therapy, experimental and probably other things I'm not aware of. You have a disease, but treatment is assigned codes through a mess of regulations, and the result is inscrutable, at least for now.

 

[Ole Red 29]

Guys, I'm 61, so a few years away from medicare, but close enough to start paying attention. I apologize in advance if this has already been addressed elsewhere, but reading through this thread, the question of using discount apps comes to mind. We currently have private insurance, but find using an app, like goodrx, is much cheaper than using our prescription insurance. Even though the prescription payments don't go toward our deductible, we get all of our prescriptions through goodrx at a substantial savings. We currently don't have any prescriptions near the magnitude of what's been mentioned here, but was wondering if this route had been tried for these high price drugs and what the results were?

 

[harllee]

Guys, I'm 61, so a few years away from medicare, but close enough to start paying attention. I apologize in advance if this has already been addressed elsewhere, but reading through this thread, the question of using discount apps comes to mind. We currently have private insurance, but find using an app, like goodrx, is much cheaper than using our prescription insurance. Even though the prescription payments don't go toward our deductible, we get all of our prescriptions through goodrx at a substantial savings. We currently don't have any prescriptions near the magnitude of what's been mentioned here, but was wondering if this route had been tried for these high price drugs and what the results were?

My DH takes a high priced drug (Humira) and the cost through Good RX is more than using his Medicare Part D insurance. Thanks for suggesting Good RX, it can help on lower priced drugs but I don't think it helps on the very expensive drugs because there is no generics or competition for the dug companies on these.