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Cost of Camzyos on Medicare Drug Plan
Camzyos and Medicare. What am I missing? This is my understanding: Camzyos is NOT on the Medicare Formulary List. Therefore, my part D drug plan considers Camzyos a “non-covered” drug with a retail pharmacy cost of $8636 per month. My doctor filed a “Coverage Determination Request” which came back approved at a cost of $3851.77 for month one, then at a 50% Tier 4 drug for a monthly cost of $1925. All these costs are for 2024. For the calendar year 2025 it is still on the non-covered list with a retail cost of $9421 according to the representative at the Drug Plan and I was told that the doctor needs to file a “coverage determination” letter again for the calendar year 2025 to get updated quotes with the drug plan. Now my questions? For those of you on Medicare, WHAT drug plan do you have that gets the cost to a reasonable amount. Since it is open enrollment, I am willing to change. Also, I am getting conflicting information about the 2025 change that caps yearly out-of-pocket drug costs at $2000. My research online indicated that this is only accumulated for drugs on the Medicare Formulary, (camzyos is not) but the representative for my drug plan said that Camzyos would qualify for this limit. Any information or correction of my understanding is appreciated.
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Thank you! Very helplful.
I just got off the phone with UHC (plan D) to see if there were any changes for 2025 as I have paid nothing for Camzyos for all of 2024. The first two people I spoke to said that Camzyos is "out of formula" and when pressed said I can change my plan to see if it was covered. I asked to speak to someone with more knowledge and was sent to the Service Department. After asking the employee what has to be done to get Camzyos covered for 2025 she said that my doctor's office has to fill out the prior authorization form and that I needed to send that form to him. I had her email the form to me and I emailed it to my doctor's office. We had to do this a year and half ago when I started on Camzyos. She then said it would be covered.
My best advice is to keep speaking to people (move up the chain) until you get a complete explanation as to why they aren't covering Camzyos, what needs to be done to get it covered, if they won't cover it who does, etc.
My conversation changed direction when I told the service dept. employee that there was no other drug on the market similar to Camzyos so who else can I speak to get this coverage that I have had for 1.5 years.
Sorry if my post is misleading. My insurance plan does NOT include Camzyos, but I am willing to pay the $2000 out of pocket for the calendar year 2025 with the NEW 2025 maximum cap limit on drugs with a Medicare Drug plan.
otterbesewing | @otterbesewing : I greatly appreciated the information. I was flailing around and, with your information, I've more progress in the past two days than the previous weeks during my lunch hour. Thank you!
nbs | @nbs : Thank you so much for your two posts. For others who are in my boat, this is what I learned today: I was happy to read the United Healthcare Service Dept. was hepful to nbs, but it is not always helpful. I was on the phone for 2-1/4 hours, talked to 11 different people and then was told to call back on Friday to speak to a manager; the managers were all tied up today. I have a Part G with United, but I don't have Part D coverage yet; this may have been the problem. From a pharmacist I know, I learned that you can find (in theory, I haven't tried it; I think it's on the first screen under something like see plans/drug coverage) the cost of Camzyos under different insurers on Medicare.gov; that you have to be enrolled in Medicare Part D before any insurance company will tell you if they'll add Camzyos to their formulary and they'll cover it (I find this scandalous; It's like buying the promise of something only for that promise to be potentially be denied); once I have Part D coverage, I was told by my health care provider (UCSF) to call their specialty pharmacy on January 2 to provide my BIN/PCN (I believe); they'll send a prior authorization form to my cardiologist and they'll send the completed form to the insurance company. In addition, I just recently started on Camzyos and my prescription is being provided by Bristol Meyers until the end of the year; the person I spoke to at the UCSF specialty pharmacy said the drug company will provide the drug for the first month or two of 2025 until my plan kicks in. More than one person I spoke to today said Camzyos will fall under the $2000 max out of pocket ceiling for Medicare drug coverage; I hope they are informed. Finally, an insurance broker said that given that United covers Camzyos for someone on this forum, its likely/possible they'll cover it for others.
Again, thank you all for the information you've shared. It's helped me immensely.
nbs | @nbs :
AARP has two Medicare Rx plans with United Healthcare. Since I have a Medigap plan through AARP and you received full coverage for the drug, I thought I'd buy my Part D plan from them as well. The two plans are:
1) AARP Medicare Rx Preferred from UCH (PDP); Part D; Plan ID:
S5921-413-0
2) AARP Medicare Rx Saver from UCH (PDP); Part D Plan ID: S5921-376-0
The premium for the Saver is about $9 more/month than the Preferred and the drug cost is about the same $118,028.84 vs. $118,078.04 (mail order pharmacy).
May I ask which plan you have? I'd like to do what I can to make sure the drug is covered.
Thank you!
Please, tell me more: I have UHC Medicare Advantage PPO and after lots of calculations about Camzyos, the UHC customer rep said it would be about $500 to $800 "out of pocket". This means at least $6000 out of pocket for me, which I don't have because I'm helping other family members who are struggling financially due to unemployment, displacement from climate-crisis events in FL and CA etc.
Should I google Catastrophic Coverage or would that be a waste of time?
I guess I could afford about $100 a month ($1200 a year) but not much more. I read that it takes about 20 years for an FDA approved drug to go "generic". I won't be on the planet in 20 years! Also . . .
Does Walgreens actually provide prescribed Camzyos?
What if we "middle-classer-retirees" are just above the cut-off for the patient assistance program from Bristol Myers Squibb?
This is my third year dealing with how to pay for Camzyos. Each year has been stressful. At the beginning, no one knew how to pay for it. I have had and still have all costs not covered by Medicare covered by a grant so I have no out of pocket expenses. My understanding is that under the Biden administration, a $2000 cap was put on Government Medicare (not an Advantage Medicare plan) for medication - at least the catastrophic category which is Camzyos. That is definitely the case for me this year. My pharmacy is Optum. You can only get Camzyos from certain pharmacies and they have to be part of the REMs program. My prescription is mailed to me every month. I would have had to pay a $1985 copay for the first month (January 2025). However, I found out that I still have a grant (I had no idea I had a grant) that not only covered this year's $1985 copay but will cover up to $10,000 of pharmacy costs. This grant has to be renewed each year. Since my copay is covered I will not have any more costs for Camzyos for 2025.
I can only offer advice based on how I am getting Camzyos covered but let me share this with you. First of all, my doctor's office was responsible for setting up my grant and Optum pharmacy also assisted me telling me how to initiate the grant for 2025. The grant is a Copay Assistance Card. My grant comes from the HealthWealth Foundation. My doctor's office initially did the paperwork to set it up. The only thing I had to do this year was contact the Foundation to get the grant Pharmacy card information and provide it to Optum.
If I were in your position I would talk to my doctor's office and ask for them to help you find a way to cover your costs. My doctor's office also set up my pharmacy (Optum) and they were told by BMS which pharmacies they could contact. You need to get help for all this. There was no way I would have known what questions to ask to get financial assistance or how to find the right pharmacies. I hope this is helpful and that I wasn't confusing. It is a confusing process.
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2 ReactionsBristol Myers Squibb, the maker of Camzyos, has a Patients Assistance Foundation. If you qualify you can get Camzyos for free. https://www.bmspaf.org/
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3 ReactionsHi - My research shows that Medicare does not cover Camzyos under any of the "Plan Ds" since it is a Tier 5 formulary drug. This means that you only have your supplemental plan, if you have one, and Bristol Myers to help you with costs until this changes. Except for the folks in Canada, it seems like this is coming in somewhere between $17,000 and $25,000 - ish per year! During open season, we tried to get our supplemental insurance to tell us which of their plans would cover some of Camzyos which they would not do until we had a prescription and were working on pre-authorization - it was infuriating - so we were unable to choose what could have been the best supplemental plan to help us. This was United Healthcare. I hope others here will answer you - I don't completely know if I am correct or how much this varies from person to person.
http://www.Healthwell foundation.org
they have a grant program for Camzyos.