My name is Dusty.
I’ve had UC since 2006. I will turn 65 later this year. I am currently on Entyvio and Budesenide for my main treatment. I am worried about how I am going to get treatment once I go on Medicare.
Is it possible that I could pose a question to the group to ask if people have gotten coverage for the more advanced biologics with Medicare?
And, if so, specifics on what they recommend for coverage?
Let me know.
I’ve had UC since 2006
I am on Medicare and have been receiving Entyvio Infusions for 2 years. I also have a Medicare Supplemental insurance plan. I haven’t had any problems with coverage other than Medicare will only cover infusions every 8 weeks. I haven’t had to pay anything.
Regarding Budesonide, my Prescription plan required me to pay a large copay every month. My Physician slightly altered the Budesonide Rx to a minimally different dosage which allowed a compounding pharmacy to make it. I only had to pay $70 out of pocket which was considerably less than the CVS copay.
Btw, once I was established on the Entyvio he stopped the Budesonide.
My suggestion is to seek out a Medicare Insurance consultant to help you get the best coverage for your needs. There is no charge for the consultation.
Thank you for the response Joanie. Can you tell me specifically which Supplemental Insurance you have? Also, can you provide some insight on where I should look to find a Medicare Insurance Consultant?
I am on medicare now and taking Remicade. Drugs that are to be administered bya physician are called Part B drugs, meaning they come under medicare Part B. If a patient takes a medicare advantage plan or medicare supplement plan there is an out of pocket maximum for Part B treatments and drugs and the patient pays 20% of the cost Part B treatments or drugs until the out of pocket maximum is reached. In my case the out of maximum is $1000 per annum. I pay 170 dollars per month as medicare premium. The insurance company (scan health) pays me 100 dollars towards Medicare premium under the plan. You can consult an agent and take a Medicare advantage plan or a supplement plan that is best suited for you. The out of pocket expenses would be in the range of 100 to 500 dollars per month depending upon your plan.
Both prior comments contain errors.
If you get a supplement plan G, you will have Zero copay for infusions under part B.
If your Dr. prescription calls for infusion every 4 or 6 weeks, Medicare will approve it.
I have been getting Entyvio free for 2 years on Medicare.
Of course; if you take a supplement plan you have no copay for part B drugs but you have to pay $ 200 or more per month as premium, which would be more than what you would pay under an advantage plans as most of the advantage plans have out of maximum of about $ 1000 or less. However, a supplement plan lets you to go to any doctor accepting Medicare patients while an advantage plan requires you to go to the doctors in network and requires referral.
I believe the same is true for a supplement plan N, with the exceptions of 1) paying the annual Part B deductible, and 2) possibly paying a Part B excess billing charge if you live in a state that allows these charges (up to 15%). Currently Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont do not permit excess billing.
Harry H Westerman,
There were no errors in my response.
Thank you for your response Harry. Any chance you could share specifically how your Medicare solution is structured (exact plans, etc…)? It sounds like you have a good solution. That would be very helpful.
Supplement plan G from ANY Medicare provider will pay the 20% copay for any drug infused at the doctor’s office. Medicare part B pays the 80%. Plan costs vary from state to state. I’m paying about $200/month for my supplement plan. I have had 3 separate surgeries and a colonoscopy n the last 3 years. My out of pocket was zero. I do have a ~$300 annual deductible. You can also go to any doctor that takes Medicare.
That is very helpful Harry. Can you tell me who you have for Part D, what you pay, and how well it covers your prescription meds? I’ve got a bunch of prescriptions that I’m definitely gonna need help with.
Part D strategy. Determine the generic dose and frequency for each med. Go to Medicare.gov. Go to part D plan section. Put in your drugs, try to always use Generic names. Let it search for your best plan. Expand the details for individual drugs to see what you’re being charged for each drug. If they are still too expensive, go to PharmacyChecker.com and search for those generic names. You can buy much cheaper offshore.
All of this can take hours of work depending on how many drugs you need
I plan to start taking Entyvio. My health coverage is through Kaiser Advantage plan of Washington state. I am confused about the co-pay.
Can someone please explain or where I can find answers?
With an advantage plan have to pay 20% of the cost of the Part B drug until you reach out of pocket maximum. If you do not know out of maximum for your plan, please speak to a representative of Kaiser or an agent who can help you enrol in the plan.
Dusty…I have been on Remicade, Entyvio, Stelara and Simponi infusions. All covered by Medicare. The problem comes up if you have to take the injections. Medicare will not cover the injections and when I applied for financial help I was told “ Congratulations. You have been approved for help. The injections will “only” be $2400/month.” I have had reactions with all of these infusions and have now been referred to Cedar Sinai Gastroenterology Group to see what they can do for me. I am currently on Balsalazide Disodium and it seems to be keeping me in remission. I was diagnosed with UC right after I retired. Just not right. I hope this message helps a little bit. Looking forward to seeing what everyone else is doing. Good health, my friend!!
Shannon, I am on Humira injections and will be going on Medicare the first of 2024. Are you saying Medicare will not cover Humira? Teresa
Best of luck Shannon. Thank you for the response.
Thank you for the comments everyone. This is extremely helpful.
I didn’t read all the responses so I may be repeating somethin. It depends on where in the US you live. I’m in Medicare with a supplemental plan.
Look for an AGENT who specializes in Medicare & supplemental insurance. Also you can go to the Medicare website & investigate the plans they offer in your area. Frankly an agent will be more helpful. Google medicare agents & what kinds of questions you should ask the agent. That’s where to start. Make SURE you understand the time limit you have to change your plan. Sometimes a physician will leave a plan and then you get stuck trying to replace someone you’re happy witg. Good luck
I have been on Medicare along with a United HealthCare supplement (Plan F) for 7 years and pay nothing for my treatment. While I do pay $200 for the supplement it is well worth it as I pay absolutely nothing to any doctor or for any test or hospital stay.