Lupron and Medicare Part D

You may not qualify for a Medicare supplement (Medigap) plan as you already have a cancer diagnoses. Supplemental plans are underwritten by an insurer and preexisting cancer of any type can be a knockout factor and may result in denial or coverage. If you are granted coverage, the question is at what price they charge. It will likely be high due to the preexisting cancer diagnosis.

Instead, look at a 5-star (preferred if you can find one) or 4-star Medicare Advantage plan with a Plan D drug plan that includes Lupron in their formulary. It’s generally a Tier 5 drug which are pricey. You can’t be denied and most 5 or 4 star plans are every bit as good, if not better than Medicare supplemental plans. Work with a qualified insurance broker near your primary residence as they will compare all the plans for you in your area and don’t fall for the Medicare Advantage plans you see on TV commercials.

Also check for copay assistance that maybe available from the manufacturer, Abbvie.

I recommend a Medicare supplement plan, if you can afford it. For many years, I had a Medicare advantage plan and before I had high risk prostrate cancer that worked great and was cheap. My doctors who were also my clients ( I am a lawyer ) recommended that I change to a Medicare supplement. I found that several high end facilities would not accept Medicare advantage and that disturbed me as I have a high risk PC and my wife has serious heart and lung issues. I tried to switch to a Medicare supplement and I found that I insurance companies would not allow us to switch from the Advantage plan to a Supplement plan. Luckily, my blue cross advantage plan elected to no longer cover charges at the excellent facility that took care of me. At that time and because of that insurance plan change, I was able to switched to a much more expensive Medicare supplement plan. Blue Cross Medical Supplement has covered my expenses. Being able to be taken care of, at an excellent facility is presently, more important to me than saving money.

Thanks.

The more I study all this health insurance stuff, the more confused I get.

Maybe my question should be: If I have pre-existing cancer when I turn 65, is Lupron covered in part B or part D?

Maybe this is my answer (from the University of Google): "Medicare Part B primarily covers outpatient care and services provided by physicians. When it comes to medications, Part B typically covers drugs that are administered by a healthcare professional in a clinical setting. Lupron often falls into this category because it’s usually given as an injection in a doctor’s office."

Call your oncologist’s nurse or their social worker and have them verify that to be correct. Lupron can also be self-injected and therefore would be covered under Part D. https://www.mskcc.org/cancer-care/patient-education/intramuscular-injection-of-lupron#:~:text=An%20intramuscular%20injection%20is%20an,to%20do%20it%20at%20home.

I like this forum and I think it's great that you asked, but I suggest you also research this topic on medicare.gov. There's a lot of information there and you can call and talk to someone at medicare.gov. That said, here's a few things to consider: I'm no expert on Medicare, but I believe during your open enrollment period when you're signing up for Medicare that you cannot be denied any supplemental medigap policy, nor can they charge you more for a preexisting condition like cancer. But if you miss that initial open enrollment period, then you no longer have any federal law protections. So it's real important that you sign up on time. Also, you really need to pick a good supplemental plan because your rights to switch to another plan are very very limited and subject to acceptance by the company. Frankly, it's probably wise to assume that once you pick a supplemental plan you really won't be able to pick another plan. So choose well. Unlike the medigap supplemental plans, I believe you can switch Part D prescription drug plans each year during open enrollment without any penalty. But medicare.gov offers tools to estimate your drug costs on the various plans when you enter the drugs you use, so that's the best place to find out the best Part D plan to be on. One last thing I feel I should mention. On medicare.gov you can easily compare the benefits of each supplemental medigap plan offered in your state. Within each type, there's be a long list of companies offering policies at different costs. Be aware some of the policies monthly cost will be "age attained" and some will be "community pricing". Just be aware of that difference when you're comparing monthly premium costs. With all this said, my personal 2 bit opinion is a Plan F medigap policy will generally give a person the most options for where they can get medicare care, and best protect them from unplanned costs. But that's just my personal opinion.

I would recommend either through your employers plan or a recommendation of a good Medicare assistant. A good one can help. Like others have said Medicare advantage are not covered everywhere. Mayo Phoenix does not take advantage plans. I would also get a supplement. A&B are 80/20. It would not take long to rack up medical bills. Supplements pick up the balance. I think mine is plan F but your younger and they have changed plan F. My supplement is $250 month apiece.(wife and I). I use Humana for the silver sneakers. But they are all by law about the same. Plus I found advantage plans may be more local in their coverage. I wanted to be anywhere in USA and have the same coverage. I then have a drug plan. I have found you have to shop those for the best coverage for the drugs you are taking. They all are different. Your medicare assistant can help here. Mine runs about $15 month. There are some penalties if you do not sign up at 65 and your acceptance is not guaranteed. I think at 65 your are guaranteed coverage. I switched my supplement at 67 from United Health Care to Humana because UHC quit offering silver sneakers. I had to go through the approval process.

Very helpful suggestions. Thanks to all of you.

Maybe I just won't turn 65. I could stay 64 for a couple of decades. Though 24 would be better.

I still have 6 months to figure all this out. I just chatted with a representative from medicare.gov, and he said this: "Medicare covers cancer treatment when it is medically necessary and is ordered by your doctor."

So, is Lupron a treatment or a drug or a medication?

@fortunateoldguy Actually, if @bluegill is signing up for Medicare for the first time and looking at Traditional Medicare the insurance companies that sell supplements are no longer allowed to turn him down due to cancer or any other pre-existing condition. That used to be the case but it was changed some time ago. I looked at this very carefully when I first signed up for Medicare. If he chooses to go with Medicare Advantage and later on wants to switch back to Traditional Medicare and wants a supplemental plan then the insurance companies could very well turn him down at that point in time.

@hbp also writes about Medicare and what he learned. He landed into an exception that worked for him.