Financial discussions/tips concerning expensive treatment

@ans. I know how very complicated this is. I’m going to share my understanding as I was prescribed Evenity which is covered under Medicare Part B. I’m also going to share information I’ve learned about the costs of medications when the medication is administered by you vs. in an infusion center.

I get Evenity injections monthly at an infusion center. Because I go to an infusion center my injections are covered by Medicare Part B. I have Original Medicare so once I’ve met my deductible for the year ($233) there is no cost to me for these injections. It’s important to note that I have Original Medicare not Medicare Advantage.

For your commercial insurance company it becomes more complex. I would suggest asking your endocrinologist where you will receive your injections. Will you self-administer? Can you get them at the endocrinologist’s office? Or will you go to an infusion center or hospital to get the injections? My understanding is that where you get the injections will inform your insurance company in how the medication will be paid. Since your current endocrinologist suggested that you can work with their finance person I’m hoping that they will be very helpful to you.

I want to encourage you that you are asking all the right and very complicated questions.

I’m going to suggest a place where you can get more information. I listen to this radio show every week. Do you get Sirius radio on your car or at home? There is a show on Thursdays from 12-2 (EST) called Health Care Connect. It’s a call-in show and all they talk about is health care insurance. You might consider calling in to the show and asking your questions. Here is the link for the experts who host this show:

Health Care Connect-RubinHealth:

— http://rubinhealth.com/about/

Did I provide you with some information that is useful? Will you return and let me know what you find out and how you’ll proceed?

I urge you to do your own due diligence on the costs before starting treatment. My doc's office made assurances too - but it didn't pan out. All their insurance person can do (which I do understand) is share all suggestions/contact info they have for pharma company and other available financial avenues - but that doesn't mean you'll qualify - or that what's available will cover enough to still be doable for you.

Case in point: I have commercial insurance through my employer. I had to pay full retail price of $2700/month until I met my deductible. Then $700/month AFTER I met my insurance deductible. I was able to get Tymlos help to cover majority of 1st year, with a few months out of pocket. But now Radius tells me I may not get a 2nd card for Year 2. This floored me: why aren't they transparent about that upfront? Seems misleading to start a patient on a 2-year regimen with promise of financial help, then cut them off after year 1, halfway thru treatment.

I'll mostly likely have to abort and just switch to a maintenance drug next year. I wouldn't want anyone else to find themselves in that position.

Definitely check the financial end yourself: the doc's staff can definitely help, but they can't really promise anything.

@katwhisperer -Just making sure I understand you. So those were the prices your commercial insurance would have charged you , but instead you had assist from Radius for most of that year with having to pay the $2700/month the remainder -- How many months did Radius have a coupon that covered the cost for you, or was it till they paid out a certain amount and then that was it? Can I assume that Radius is the system Tymlos has to set up to help patients, or does it also cover Forteo as well? Thank you so much for your information- cause how much something costs could be a deciding factor in which medication to go with. I think the dr's don't really get that!! Thanks again and wishing you the best as you attempt to get the better treatment for the second year!

@ans. I know how very complicated this is. I’m going to share my understanding as I was prescribed Evenity which is covered under Medicare Part B. I’m also going to share information I’ve learned about the costs of medications when the medication is administered by you vs. in an infusion center.

I get Evenity injections monthly at an infusion center. Because I go to an infusion center my injections are covered by Medicare Part B. I have Original Medicare so once I’ve met my deductible for the year ($233) there is no cost to me for these injections. It’s important to note that I have Original Medicare not Medicare Advantage.

For your commercial insurance company it becomes more complex. I would suggest asking your endocrinologist where you will receive your injections. Will you self-administer? Can you get them at the endocrinologist’s office? Or will you go to an infusion center or hospital to get the injections? My understanding is that where you get the injections will inform your insurance company in how the medication will be paid. Since your current endocrinologist suggested that you can work with their finance person I’m hoping that they will be very helpful to you.

I want to encourage you that you are asking all the right and very complicated questions.

I’m going to suggest a place where you can get more information. I listen to this radio show every week. Do you get Sirius radio on your car or at home? There is a show on Thursdays from 12-2 (EST) called Health Care Connect. It’s a call-in show and all they talk about is health care insurance. You might consider calling in to the show and asking your questions. Here is the link for the experts who host this show:

Health Care Connect-RubinHealth:

— http://rubinhealth.com/about/

Did I provide you with some information that is useful? Will you return and let me know what you find out and how you’ll proceed?

This forum really needs someone very knowledgeable about Medicare to step in and try to make sense about all this in a more generally helpful way. There seems to be too many variables from one person to another that makes each individual situation unique and also there seems to be quite a bit of simple misinformation.

For example, Medicare Part B pays 80% of the eligible amount (after annual deductible) and you or someone on your behalf pays the other 20%. Please consult your friend Mr. Google which will lead you to the authoritative HHS info.

IF you do not pay that other 20% then you have either a supplemental plan (private insurance or employee retirement plan) or another governmental program that does pay or a pharma program. The other governmental programs are state-specific and usually income-dependent....hence creating much of the variation about what and how much is covered. The pharma programs appear to be here today and gone tomorrow.

IF you go to an infusion center to receive your osteo treatment, there is a rather complicated formula for whether Medicare considers this a Part B benefit or whether the treatment is covered under your drug plan.....I do not recall all the specifics but one of the factors I do remember about Part B eligibility is whether you have had a previous fracture.

Medicare Advantage is required to cover the same medical benefits as original Medicare. How you pay for those medical benefits is different.

Medical providers are the absolute worst source of info about the financial picture of medical care. Inasmuch as they all seem to have a similarly vacuous response, I suspect there may be a course at med school that teaches a practitioner what to say when a patient brings this up as a consideration.

If I had the time at present, I would contact the Medicare Rights Center. In my opinion, they have the most reliable info about Medicare coverage and cost. Perhaps someone here could convince a staff member at that Center to be assigned to this forum to help sort out all the coverage and cost questions that come up. I have no available time to do this until after the new year.

On the bright side of those receiving Prolia treatment, the patent is set to expire in early 2025 so there may then be available a generic like what is available for Fosomax and Bonita.

This forum really needs someone very knowledgeable about Medicare to step in and try to make sense about all this in a more generally helpful way. There seems to be too many variables from one person to another that makes each individual situation unique and also there seems to be quite a bit of simple misinformation.

For example, Medicare Part B pays 80% of the eligible amount (after annual deductible) and you or someone on your behalf pays the other 20%. Please consult your friend Mr. Google which will lead you to the authoritative HHS info.

IF you do not pay that other 20% then you have either a supplemental plan (private insurance or employee retirement plan) or another governmental program that does pay or a pharma program. The other governmental programs are state-specific and usually income-dependent....hence creating much of the variation about what and how much is covered. The pharma programs appear to be here today and gone tomorrow.

IF you go to an infusion center to receive your osteo treatment, there is a rather complicated formula for whether Medicare considers this a Part B benefit or whether the treatment is covered under your drug plan.....I do not recall all the specifics but one of the factors I do remember about Part B eligibility is whether you have had a previous fracture.

Medicare Advantage is required to cover the same medical benefits as original Medicare. How you pay for those medical benefits is different.

Medical providers are the absolute worst source of info about the financial picture of medical care. Inasmuch as they all seem to have a similarly vacuous response, I suspect there may be a course at med school that teaches a practitioner what to say when a patient brings this up as a consideration.

If I had the time at present, I would contact the Medicare Rights Center. In my opinion, they have the most reliable info about Medicare coverage and cost. Perhaps someone here could convince a staff member at that Center to be assigned to this forum to help sort out all the coverage and cost questions that come up. I have no available time to do this until after the new year.

On the bright side of those receiving Prolia treatment, the patent is set to expire in early 2025 so there may then be available a generic like what is available for Fosomax and Bonita.

@rjs. You wrote "This forum really needs someone very knowledgeable about Medicare to step in and try to make sense about all this in a more generally helpful way. There seems to be too many variables from one person to another that makes each individual situation unique and also there seems to be quite a bit of simple misinformation."

I will ask if there is someone from Mayo Clinic to come in to our discussions for topics like this. At the present time I think your suggestions are very helpful including contacting the Medicare Rights Center. Do you have a phone number or website to share for this?