1. < Hypertrophic Cardiomyopathy (HCM)

Cost of Camzyos on Medicare Drug Plan

Posted by otterbesewing @otterbesewing, Oct 19, 2024

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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hncm | @hncm | Feb 10 2:45pm
In reply to @joycehocm "Hi - My research shows that Medicare does not cover Camzyos under any of the "Plan..." + (show)
@joycehocm

Hi - 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.

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I have UHC Advantage PPO which supplements Medicare, and might need Camzyos in the near future, once I find out I have HOCM which is treated by Camzyos or NHCM (nonobstructive) which is not treated by Camzyos (nor any other drug--yet). So are you saying that if I have HOCM and need Mavacamten (Camzyos) I am facing a bill of about $2000 a month since I don't qualify for the Bristol Myers $$ (cut off of $34,000 max annual income?). No way can I afford $2000 a month or even $500 a month! If so what other health insurance plans (for retirees) WILL cover Camzyos 100%? I wonder if I can drive over the border into Canada and buy Camzyos there (I live in WI part of the year)? Maybe between Canadian lower prices for Camzyos and if they take my UHC, I might be better off than dealing with USA absurdities?

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hncm | @hncm | Feb 10 7:44pm
In reply to @peggynurse "www.Healthwell foundation.org they have a grant program for Camzyos." + (show)
@peggynurse

http://www.Healthwell foundation.org
they have a grant program for Camzyos.

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You have to have an adjusted gross income of less than $78k in order to qualify for a grant.

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ladydi7 | @ladydi7 | 4 days ago
In reply to @jaymaysea "You are correct Camzyos is a “non-covered” drug so it does have to be "authorized" based..." + (show)
@jaymaysea

You are correct Camzyos is a “non-covered” drug so it does have to be "authorized" based on a justification from your doctor. My authorization was for one year. I was already in the "donut hole". So, my monthly cost were estimated to be around the $1900 you mentioned. I am not sure how the 2025 out of pocket drug cap of $2,000 will work.

But, thank God I get patience assistance from Bristol Myers. The income limit is higher than you might think.

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I was directed to Healthwell in Maryland, it is a non-profit that can award funds for different diseases/conditions. My co-pay was $1,576. Per month, I was awarded $10,000 for one year to defray the cost of Camzyos. I have since discontinued taking it in order to have a septal myectomy.

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