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Medicare Plan D for someone with NTMs

MAC & Bronchiectasis | Last Active: Oct 29 3:36pm | Replies (14)

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Each state has its list of Part D providers available. I am in Delaware. In reviewing the formulary lists and costs the best 2 companies I see are HealthSpring (previously Cigna) and WellCare. I looked at drugs for pseudomonas, MAC and some of the drugs to treat Abscessus. HealthSpring seems to cover Nuzyra (for Abscesses) WellCare doesn't cover that drug.

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Replies to "Each state has its list of Part D providers available. I am in Delaware. In reviewing..."

@sherrig I just went on medicare.gov to compare drug costs for all local Medicare Advantage plans and the lowest annual out of pocket for Nuzyra was about $170,000 (maybe it was $117 K but pretty sure it was the higher). So, though it is covered, it doesn't really matter due to the copay (at least for me here in AZ). For Abscessus there is another problem: I was diagnosed with MABC and my insurance denied coverage for Nuzyra since it was not FDA approved for Abscessus or yet considered "recommended" treatment. So, for some NTM's, it's covered but not abscessus. My local ID wrote 3 appeals, but all were denied on the grounds that it is not recommended treatment. This was about 5 months ago.

@sherrig I went back and double checked, sure enough Healthspring had $2100 annual cost for Nuzyra. Humana listed $234,000-yikes. Good to know. Thank you! Brinsupri didn't come up.

@sherrig I spoke to HealthSpring today and learned NJH is not in network with NJH. I will keep looking-and hope I find something prior to December 7th.