Spendy drugs

[GaryInCO]

Well my retirement is going to be a bit less luxe than I thought. In 2019 I was diagnosed with a form of lymphoma. Exact same crap that killed my dad 20 years ago. Fortunately the treatments have vastly improved in the last 5 years or so, and for now I'm doing fine.

These treatment drugs are breathtakingly expensive -- THIRTY THOUSAND DOLLARS a MONTH, for a couple of pills a day. For the last 6 months I've been taking them "for free," because my doc's office set me up with "copay cards" from the pharma co's that paid 100% of the cost. Not even any copay. BUT the cards only work with private insurance. Next month I turn 65 and, as far as I've been able to tell, you're forced to go on Medicare at 65. Part D plans cover 95% of drugs, which is great for most people. But 5% of $30k is $1500 a month. So my Medicare/drug costs will work out to roughly $300 premiums, $1500 out of pocket for the 5%, and $3600/yr to get to the "catastrophic" 95% coverage level -- total of about $2100 per month out of pocket. That will put a dent in the beer-money budget.

There are grants and assistance programs available, but you basically have to be destitute to qualify. My Social Security alone will pay more than you're allowed to make. So since I've done the "right thing" and saved for retirement, I get whacked with these drug costs. Which is still better than being broke enough to qualify for aid.

I really can't complain. Much. This is a much better alternative than my dad had. But it's pretty annoying that Medicare is $600 more than BCBS, and I won't benefit from the "cheap insurance for retirees" that is supposed to ease your golden years.

Of course, it would be a lot MORE annoying if these solid-gold drugs weren't available, and I was looking at a 6-12 month survival time, sooo... I'll quit whining now.

Any insights or brilliant suggestions, other than "suck it up, buttercup" and "getting old ain't for sissies" ??

 

[RunningBum]

Ouch! Maybe a little help, you'll probably have enough to deduct medical expenses from your income taxes. Kind of like giving you a sponge to mop up a lake, but it's something?

 

[target2019]

I stayed with private insurance and only signed up for Medicare Part A at 65.

The survival outcome for my spendy pills is 6 months average. My co-pay is $5 after subsidy by drug company. When I looked at what price the Rx was submitted at, it was about $22k per month.

 

[ivinsfan]

I stayed with private insurance and only signed up for Medicare Part A at 65.

The survival outcome for my spendy pills is 6 months average. My co-pay is $5 after subsidy by drug company. When I looked at what price the Rx was submitted at, it was about $22k per month.

Op be very careful with this
I have a friend using pricey drugs and his part D printout shows Medicare helping pay for by Medicare under some kind of discount program. Shop very carefully for your Part D plan they are not all equal. Ask your doctor for suggestions

Hope you continue to do well.

 

[MissMolly]

Maybe consider an Advantage plan? With my Advantage plan I pay $110/month for a drug that my plan pays almost $12,000/month.

 

[Sarah S]

Apparently you can choose to stay on an aca plan and refuse medicare. You would not be eligible for subsidies and if you ever wanted medicare you might owe penalties source: https://www.healthcare.gov/medicare/changing-from-marketplace-to-medicare/

 

[Koolau]

This is a tough one. I guess my first reaction would be "Thank God - and the Pharma industry - that someone came up with an effective treatment when there wasn't one 20 years ago." Then it becomes "Please God, help me navigate the maze that is our amazing and effective HC system that costs so much that not everyone will be able to participate." I don't have an answer - but I keep praying - and YMMV.

 

[CSdot]

That sucks!

https://www.goldencapitalist.com/residency/

 

[ivinsfan]

Op are you certain this drug cant/won't be covered under part b.....ask your doctor...or can Medicare or the drug company directly

Cancer meds are sometimes treated differently.

 

[Graybeard]

You don't have to sign up for Medicare but if you don't within I think 63 days after your birthday then for every month you could have been on MC but weren't you pay a penalty for the rest of your life if you decide to go on MC in the future. The penalty is real, I'm not 100% sure about the grace period before they start to fine you.

For Tier 5 drugs, the most expensive, the 5% you pay is once you get into "catastrophic coverage", prior to that it is like 29 or 30% you pay and if IIRC after that and before catastrophic coverage I think there is no coverage. Yes, it can be expensive. I haven't looked at that for 4 or 5 years but I do remember it works like that for the Advantage plan I have but there are tons of plans. You should work with someone that helps people chose a plan. They don't charge you, IIRC the insurance company and or the government picks up the cost.

 

[GaryInCO]

Yes Graybeard, that's the $3600/yr I mentioned -- to get into "catastrophic" coverage. Which is much better than I thought. It's something like $7500 to get to catastrophic, BUT the count the insurance contribution as well. So my OOP will be about $3600.

 

[target2019]

I stayed with private insurance and only signed up for Medicare Part A at 65.

The survival outcome for my spendy pills is 6 months average. My co-pay is $5 after subsidy by drug company. When I looked at what price the Rx was submitted at, it was about $22k per month.

Op be very careful with this
I have a friend using pricey drugs and his part D printout shows Medicare helping pay for by Medicare under some kind of discount program. Shop very carefully for your Part D plan they are not all equal. Ask your doctor for suggestions

Hope you continue to do well.

I'm not the OP, and don't wish to detract from his thread. But I think his situation is similar to mine. I was pointing out that after Medicare Part A signup at 65 one can continue to use private insurance (which usually includes coverage similar to Part B and D). An important caveat is that this is only ok so long as you are still working (or spouse is) and your private coverage stays in effect.

After 2-3 years of various operations and treatments I can say that our private insurance has paid an incredible amount of money for everything that happened outside of hospital admission. And of course Medicare Part A paid the incredible ticket for everything else while I was admitted to the hospital.

Along the way I've been expecting financial ruin but continuing with private insurance and Part A have worked well in my favor. But like OP there is a transition to all Medicare that arrives someday. Ours will be 6/1/2022.

Of course every situation is different and I wish OP well fighting through all this. So long as he signs up for Part A on time, private insurance will work, Medicare Part A will work, and so on. If it is his private insurance, and it will expire when he retires, then it is time to try Boomer Benefits or something similar to see what is out there, and then make choices.

The drug company discount is tricky. Mine pays up to $25K in a calendar year. I'll worry about it running out when it does.

If I was single I'd still be working for health insurance, but I know the plans my jobs offered where no where near what the spouse gets through a hospital job.

 

[freedomatlast]

Can you buy the pills cheaper from Canada or other countries?

When I was pricing medicine for my mother, Rx from Canada was a small fraction of the cost as compared to the USA.

 

[DireWolf]

I think it’s pretty crazy that there is no OOP Max with Medicare Part D. Medicare will end up costing me much more than my (very good) ACA plan. I’ve plugged in the immunotherapy drugs I’m most likely to be on when my cancer (stage IV RCC) inevitably returns and I’m expecting to pay 20K+ a year (these are typically combo drugs, and one drug is inpatient IV under plan B, but the other is oral under part D). So far looks like Advantage plans have similar fee structures (at least in my state).

 

[MissMolly]

This is my drug plan under my Advantage policy. Disclaimer: This is an employer-provided (State Retirement System) plan. I have no idea how this may vary from plans available to the general public). Also, I have no donut hole.

 

[ivinsfan]

I think it’s pretty crazy that there is no OOP Max with Medicare Part D. Medicare will end up costing me much more than my (very good) ACA plan. I’ve plugged in the immunotherapy drugs I’m most likely to be on when my cancer (stage IV RCC) inevitably returns and I’m expecting to pay 20K+ a year (these are typically combo drugs, and one drug is inpatient IV under plan B, but the other is oral under part D). So far looks like Advantage plans have similar fee structures (at least in my state).

Well It's my understanding that some oral chemo drugs are covered under Part B....I think the doctors and drug companies are pretty good at helping control those costs.



Wishing you good health!

 

[GaryInCO]

freedomatlast, interesting idea. It does look like my drugs are available from Canada, but at about 2/3 - 3/4 of the domestic price. And I suspect the insurance companies might not cooperate very well with gray-market drugs. I'll look into it but I doubt it'll work.

DireWolf, I'm looking at $18k per year for the 5% co-insurance, so I empathize. I'll be looking for ways to reduce that.

 

[DireWolf]

This is my drug plan under my Advantage policy. Disclaimer: This is an employer-provided (State Retirement System) plan. I have no idea how this may vary from plans available to the general public). Also, I have no donut hole.

Wow. Yeah, all the ones I’ve looked at in NC just have the greater of <some small amount> or 5%, without that 30 day supply max. What state are you in? Wondering if it the state or the employer-provided nature.

 

[Bamaman]

I'm so sorry for what you're going through, and getting on the right Medicare program will be of the utmost importance. You also want to continue with the best of physicians, and Medicare Advantage is NOT the program for that.

We've almost lost count of my wife's surgeries the last 3 years and I'm a type II diabetic on an insulin pump. We have a AARP United Healthcare Plan F supplement which virtually pays for everything (but medicines.) It's the top of the line supplement. What I like is that we have control of the hospitals and the SuperStar physicians for our specific health issues.

I go into the Medicare website yearly and put all our meds into a database. It tells me what the best Plan D is for our prescription needs in our region. My $800+ monthly insulin costs me $105 now, but it's thrown me into the "Gap" for now.

 

[harllee]

DH is in a similar situation to that of the OP. He has to take Humira for his medical condition and it is also very pricey. Like the OP the drug company paid for Humira while DH was on private insurance. When DH turned 65 and went on Medicare and we thought he would immediately go into the donut hole and have a big out of pocket cost. DH's doctor told him about a Humira Foundation that helps people in his situation. We did not think DH would qualify due to our assets and income but surprisingly he has qualified for the past 5 years. The Foundation does not seem to care that we have large assets--they only look at income. To qualify we have to keep our income under a certain level (this year it is around $85,000 annually). There will probably come a time we can no longer keep our income this low but we have been able to do it so far. So the OP may want to look into the payment assistance available for his drug. His doctor should be able to help with that. DH's doctor says that none of his patients end up having to pay the big cost of Humira.

 

[MissMolly]

Wow. Yeah, all the ones I’ve looked at in NC just have the greater of <some small amount> or 5%, without that 30 day supply max. What state are you in? Wondering if it the state or the employer-provided nature.

KY. And like I said, it's part of the state retirement system benefits. So it could be just because of that, but looking at the policy leads me to believe it is any employer-provided Medicare Advantage plan for this particular carrier since it never references the state retirement system anywhere.

 

[sengsational]

freedomatlast, interesting idea. It does look like my drugs are available from Canada, but at about 2/3 - 3/4 of the domestic price. And I suspect the insurance companies might not cooperate very well with gray-market drugs. I'll look into it but I doubt it'll work.

Sad, but I'd bet money it won't work. The pharmaceutical development companies are motivated to "lance the boil" of unreasonably high prices through their various schemes...schemes where they control all the rules. Keep the price high, and then make rules to keep the S from hitting the proverbial F.

 

[Rocky mtn high]

My wife has gotten drugs for a few years from Canada. Her doctor helped set it up. Much much cheaper then US.

 

[Sunset]

My wife has gotten drugs for a few years from Canada. Her doctor helped set it up. Much much cheaper then US.

Works well if a person has no insurance.

Difficulty becomes if they have insurance as the insurance companies don't want to count what you spend against your deductible.
If the price differential is great it could still work.

 

[sengsational]

^True. The most advantage can be had on somewhat popular drugs that haven't gone off patent. Other, less compromised governments negotiate prices, and importing through the mail can save a ton. But I've tried (back when I needed a regular Rx) and no matter what I did, the insurance company said I was on my own if I imported the drug.