Financial discussions/tips concerning expensive treatment

I called insurance twice to double check and was told Evenity was Part B. One wanted a prior authorization and the other said it wasn't needed. I had my doc's office do one anyway. I never trust any of the reps! Nice as they are. I believe it will be given in the office so I'll see what the charge is. I was told 20% with Part B.

Ans,
If you have traditional Medicare and have chosen a Part D plan (drugs), some of those plans have a donut hole. That means that after the plan pays a certain amount toward your prescriptions, you are in the donut hole and must pay for drugs yourself until you’ve spent a certain amount. Then, you are out of donut hole and plan resumes paying. It’s a terrible way to manage someone’s prescriptions and “donut hole” is a dumb name for it. All plans are different. I am on an Aetna plan that doesn’t have a donut hole.
We are currently in the Open Enrollment period. Until December 7. You can call Medicare 1-med-icar -
And they will go over your options with you. Different parts of the country have different plans. During Open Enrollment, they add a lot of staff to answer these calls and are available 24 hours a day. I always call at some odd time like Sunday at 8pm. No waiting. When you speak to them, they can tell you whether a plan has a donut hole and when it kicks in, what premium is, whether it has a deductible, and exactly what each one of your drugs will cost under each plan. In my state, there are 45 different plans this year (2024). I am only interested in hearing about the top 3-4 plans so that is what we talk about. This has become a lot easier in last few years because the Medicare person can now see what your drugs are - or what you’ve been buying - and what plan you’re currently on. They have a scary amount of information about you, but it makes this process easier.
You can ask them to tell you what plans do not have a donut hole Or don’t have a deductible. Sometimes, a person has one drug that’s very costly snd they can ask to search for a plan that covers it.
It’s worth the trouble to make the call and have the conversation. You are protecting yourself and educating yourself. Also, if you choose a Part D plan over the phone with Medicare, they can enroll you right then. They can change you from you current plan to a new one.

Had no idea that the donut hole could possibly be eliminated by some plans. Thought it was part of the Part D statutory creation structure. Prior to Part D, I understand original Medicare did not cover prescription medication.

Do you have an Aetna Advantage plan or some sort of Aetna supplement plan?

My BC/BS PPO Medicare Advantage Plan has a donut hole.

The state of MA has a Prescription Advantage Plan that helps with expenses during the donut hole, if your income qualifies.

rjd,
No, I have traditional Medicare with a supplemental (AARP), and a Part D plan (Aetna).

@susanfalcon52 - Thank you you so much for your through answer. Much appreciated !! I just turned 66 & actually at this time only have Medicare Part A . My husband works , we still have kids under 26 so we still have our family commercial plan to help them. I’m wondering if I should get Part B , for better out patient coverage , though I’m looking to do Forteo, which WILL NOT be given at a medical facility - it’s a daily shot administered to yourself. So don’t think that will help in this matter, right???? I also, don’t know about when one can go on Part D , which is for drugs, if still on a commercial plan ? These are probably basic questions , and feel a bit silly asking , but life is crazy and busy right now and thought some people could give me some quick answers. Appreciate any and all assist !! Thanks so much to everyone!!!

ans,
One reason to go on Part B now might be that you pay a slightly higher premium for each year that you didn’t go on it when you could have gone on it. I believe this is still true.
Traditional Medicare has Part A (hospital), Part B (every thing else except drugs), and Part D (drugs). I do feel that this is a cumbersome way to manage medical care, but still preferable to the Advantage plans.
A person with little or no health problems is a good candidate for an Advantage plan. The problem is that this healthy individual may not stay that way.
I’ve posted about this here before, but it is important, so I’ll say it again. It seems that seniors fall into three groups (pertaining to health insurance):
The low income who are covered by Medicare and Medicaid 👍.
The middle group who don’t qualify for Medicaid and only have Medicare. Some people in this group cannot afford to pay for a supplement and a Part D plan. Advantage plans are attractive to those seniors.
The third group which can afford to pay for a supplement snd a Part D plan.
I believe that the second group often chooses an Advantage plan for financial reasons , but is not well served by it.
The question about Forteo is complicated. Because you are self administering it at home, it won’t be covered by Part B. What private insurance will do for you and Forteo is anyones guess. I was on Forteo for four months because my doctor was getting it from a drug rep for me. Now, I’m on Evenity which Part B pays for because I have it administered in an infusion center.
I recommend going to the AARP website and reading articles about the complex insurance options. While AARP does sell a product, I still find them to be very even handed in their reporting.
Also, go to the Medicare site. The answers are there even though you might have to dig a little.
While I always seem to be touting the virtues of traditional Medicare, I realize that it is a complex system and often want to move to Sweden.

I went on Medicare almost 1 year ago. I also have commercial insurance through the company I work for. I was on teraparatide and found a manufacturer coupon; I paid zero for my monthly medication. I am now going to Tymlos and have a manufacturer coupon that I will pay zero for as well. My Endo did help me to find my coupon because when I found out my copay was 600 monthly, I told her I could not afford it. Do the leg work and make sure you have a coupon because then you will get charged. Although my endo helped me, only because I brought it up. She had no idea that the co pay would be as high as it is. My Medicare (aarp, United Healthcare) does not cover Forteo, teriparatide, or Tymlos. I will have to look into that further should I decide to leave my job.

@ans Thank you so much for bringing together important information about all types of assistance, where everyone can share their invaluable experiences navigating the financial challenges of paying for expensive Rx treatments.

If you're under 65 without Medicare cover, you may find the thread linked below helpful.
https://connect.mayoclinic.org/discussion/any-leads-on-rx-payment-assistance-for-under-65s/

I'll also duplicate the content to-date from that thread in this one, so that it's all here in one place for everyone.

The following entries are copied from the "Any leads on Rx payment assistance for under 65s" thread:

On 11/8/23 @hopefullibrarian said:
Radius Assist for TYMOS (abaloparatide) injection therapy. Here's the link to the page that where you can access the application and review the eligibility requirements. https://radiuspharm.com/radius-assist/ You can call as well 1-866-896-5674.
Radius also offers a discount card. I don't yet know any more about it than what's in the fine print on the back side. Click here for the printable version: https://svc.opushealth.com/TymlosPOD/Documents/WebDOC84dd3bcf-deea-4b64-a02d-988b582c8080.pdf

On 11/9/23 @hopefullibrarian said:
Amgen Safety Net Foundation is a non-profit patient assistance program for Amgen medications. This includes Evenity. Like Radius Assist for TYMLOS, Amgen Safety Net Foundation has eligibility requirements. If approved, they cover 100% of the cost. Here's the link to their site: https://www.amgensafetynetfoundation.com/index.html

On 11/9/2023 @katwhisperer said
I'll briefly summarize what I posted elsewhere re: Radius Patient Savings Card (for Tymlos), in case it helps anyone. This is based only upon my personal experience using the program in 2023. (Program eligibility and rules often change, so hopefully others chime in w/their updated experiences at some point.)

1. They offer a set $ per year, loaded to your Patient Savings Card.
2. You must have commercial insurance to qualify, (like through your job or insurance you buy yourself.) Govt funded insurance (medicare, Tricare, VA not eligible.)
3. It won't cover 100% for everyone: once you deplete card's set amount, you then pay out of pocket.
4. WHEN you hit that out-of-pocket scenario depends upon your own insurance. Some get through most or all of the year free. Others are out of funds midway.
(As an example, I am billed $2600/month retail for Tymlos until I meet my 3k deductible. Then my insurance pays a portion and I pay $700/month (yes – that's the discounted rate through insurance, lol.) My Radius funds were depleted in Aug. Paying out of pocket for rest of 2023.
5. Radius only approves 1 card for you. You have to wait until the end of the calendar year to find out if they are offering the program again next year and if you can get another card. They won't say in advance.
6. If it does continue and you are approved for a 2nd card, you get another 6 months only: the "lifetime" maximum is 18 months TOTAL.
So realize you may need a "Plan B": $ from other patient support programs or paying out of pocket for what Radius and your insurance won't cover.
I don't earn a lot, but had zero luck finding other funding. Patient programs require very low income to qualify, unless one has kids/dependents living at home or already on other govt support like food stamps.
My doc won't like it, but I'll have to switch from Tymlos to a maintenance drug next yr if I can't get a 2nd card.
Good luck to everyone. It sure is a costly drug!

On 11/9/23 @hopefullibrarian said:
Before reading this, please note that Rx assistance programs can be a literal life saver. The following information is provided to help you avoid potential pitfalls. Be informed. Do your research.
If you don't already know about Copay Accumulator & Maximizer Programs, this should be an eye-opener. It was for me.
In the "Is anyone using Tymlos" discussion, @kjoy and @windyshores shared some VERY IMPORTANT information in regards to who benefits from any assistance you may receive. https://connect.mayoclinic.org/comment/959417/
Depending on the nitty gritty of your insurance policy and the laws in your state, your costs may not be reduced at all. @kjoy shared the following very helpful links. I'm sharing them again here.
Here is an explation. https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2021-AccumulatorsPolicyBrief.pdf
And here is a section of this page: https://www.crohnscolitisfoundation.org/managing-the-cost-of-ibd/hot-topic-copay-accumulator-maximizer-programs#:~:text=As%20of%20summer%202023%2C%2019,as%20well%20as%20Puerto%20Rico.
I'm sure no one wants to find that you put in a ton of work seeking out and applying for assistance only to find your insurance company saves money, but not you.