OT Rant-CoPays

[edinaman]

This isn't about colon cancer, but I think the issue could apply to cc drugs, too. For a few years I have been getting a biologic drug (injection) from my dermatologist. It's given 4 times a year. I know biologics are very expensive, but my co-pay was always $10. Well, this year I retired and had to change my health plan to Medicare. On the recommendation of my agent, I signed up for Blue Cross Blue Shield. He said they were the best with biologics. Of course, it turned out they did not cover this particular drug. They did say they would cover the first dose, which is supposed to be next week, but they would not guarantee they would cover any more doses. Well, the dermatologist's office convinced them to cover it for the next year. Now for the issue. The drug company said that by law they can't do the $10 co-pay when dealing with Medicare. I think this goes along with Congress making it law that the government can't negotiate prices with the drug companies when dealing with Medicare. The drug companies can tell them what they are charging, and that's it. Well, my co-pay for the first dose under Medicare is something like $3300! At that point I sort of stopped listening, but I think they said the second dose has a co-pay of $575. The rep from the drug company was sympathetic and said that really it's retired people who need the most help with co-pays, but they can't subsidize drugs under Medicare. They said to talk to the doctor's office tomorrow, and see if there is anything they can do to help. I don't care how much money you have, this kind of co-pay is ridiculous. From what I understand, this situation can come up with any expensive drug and Medicare. Rant done.
Jeff

[weisssoccermom]

Jeff,
While not yet ready for Medicare, we have been looking at it....getting a 'feel' for what it will/won't pay. Hubby is planning on working past age 65 so for awhile, anyway, we will still be covered under his employer plan....something I am thankful for. Question....is this drug covered under Part B or Part D of Medicare? I know that some drugs, such as chemo drugs, are covered under Part B and, as you said, don't have set copays....but rather have the 20% copay....which seems ridiculous.
While I won't mind picking up Part A because it's free, I really don't want to pick up Part B as we will still have retiree coverage via the Federal govt....but then a host of other problems arise with Medicare if you don't pick it up. They really screw those that need Medicare.
Sorry Jeff....I wish I could tell you it would get 'better' but doesn't sound like it will. My guess is it will only get worse.
Jaynee

[JudeD59]

My husband is a union member who is supposed to have one of the "Cadillac plans" you hear so much about on the news. Medical coverage has been pretty good, but when I tried to get my Xeloda, I was told it was considered a specialty drug and wasn't covered. Chemo is a specialty drug? I thought a specialty drug was something unnecessary but desired, something for enhancement, like Botox. But a potentially lifesaving cancer treatment isn't covered? It was thousands of dollars and when we protested, we were basically told, "Tough tushie."

That was stunning to me.

Judy

[alphagam]

Agree totally on copays. There needs to be so much more info out there on Medicare!!

Please know that if you delay Medicare because of continued work there is a penalty for every month delayed. My husband's employer would still allow us to buy insurance through them, but Medicare would cost more when necessary. We really are researching constantly right noe

[ziggymonster]

This is so wrong,...one of my prostate cancer drugs costs $8000 a month!!! My first copay was $1800,which dropped to $1100 the next month, then down to $300.for the next 10 months... That works out to $5900 per year just for this one drug!!! I am on fixed income and Medicare. Medicare needs the ability to negotiate with the drug companies. Congress should get off their fat butts and change this!!

[justin case]

Hmm, perhaps do your bucket list before retirement
I grew up thinking that retirement included a little time off for years of life expenditure
Someone is shitting on FDR's idea
Michael

[edinaman]

This is so wrong,...one of my prostate cancer drugs costs $8000 a month!!! My first copay was $1800,which dropped to $1100 the next month, then down to $300.for the next 10 months... That works out to $5900 per year just for this one drug!!! I am on fixed income and Medicare. Medicare needs the ability to negotiate with the drug companies. Congress should get off their fat butts and change this!!

Those costs are crazy. Unfortunately, Congress probably won't do anything to change the system. The drug companies give lots of money to our reps.

Today I decided that what I'm going through is sort of like when I was diagnosed with cc, and had no idea what to even ask. Today, after spending hours on the phone with my derm's office, BC/BS, and Medicare, all I learned was that my derm's office is supposed to submit a Predetermination of Benefits. My first thought was, what the hell is that? Why wasn't this mentioned before? If you approved the drug, why now do we do this? I have an appointment next Wednesday, and this will take how long to get approved? They did say this is a quite time of the year and approval is quick-10 days to two weeks. Well, that takes care of next week's appointment. They said without this, I could be responsible for the full cost of the drug. Also, the drug rep told me that there are two ways to get around all of this-the derm's office can buy the drug and bill the insurance company. The rep said this never happens, and my derm's office said they don't do it. The second, was the shot can be given at an outpatient facility. My derm's office had no idea what they meant by an outpatient facility. The rep said to call BC/BS and get the names of what outpatient facilities are approved. Well, I called them. They had no idea what I was talking about. I explained how this is one of their options. Finally, they gave me a phone number which turned out to be my GP, plus two local hospitals. I called my doctor's office. They had never heard of doing such a thing and transferred me to one of the hospitals. I explained this to the person at the hospital, and they also had no idea what I was talking about. Then I remembered that when I was on chemo I went one time when my onc's office was closed for a Neulasta shot to a department at the hospital called Cedart, or something like that. They transferred me to that department. The nurse was very nice, but said they deal with oncs and MS patients and eventhough what I was asking was logical, they had never done it and had no idea how to go about doing it. She transferred me to someone else who wasn't in. So, at this point I can't do anything until my derm's office does the benefits thing. That has to be approved. If it's not, I'm not sure what will happen. That still doesn't answer the question of is there a way to get around the $3000 co-pay.

[weisssoccermom]

Medicare is not more expensive if you are covered while working and there is no penalty. You will not have to pay more for any month you choose to forgo Medicare IF you are covered under an active employee plan OR under your spouse's active employee plan. There is a penalty if you choose to forgo Medicare because you are covered under a retiree plan. However, once you stop working and are no longer covered under an employer plan, you only have I believe three months (could be wrong on the timeframe) to sign up for Medicare or you will face the penalty.....which is permanent.

[vickitwo]

Reading your post about all of the hoops that you are going thru just makes me so angry. There has got to be a more simplistic and efficient way to deal with health care for all. One should not have to go thru all of this when sick and most vulnerable. What kind of society are we anyway. Is medical care and medicines just for the super rich. I am disgusted with the whole system....with the greed and partisan politics. As a society this is downright shameful.

[juliej]

Medicare is not more expensive if you are covered while working and there is no penalty. You will not have to pay more for any month you choose to forgo Medicare IF you are covered under an active employee plan OR under your spouse's active employee plan. There is a penalty if you choose to forgo Medicare because you are covered under a retiree plan. However, once you stop working and are no longer covered under an employer plan, you only have I believe three months (could be wrong on the timeframe) to sign up for Medicare or you will face the penalty.....which is permanent.

Jaynee, I've been helping my elderly neighbor with this and you have 8 months (beginning the month after active employee coverage ends or when employment ends, whichever comes first) to sign up for Part B without a penalty. It's also important to know that if you have COBRA, you still have 8 months, even if your COBRA coverage is longer.

The other confusing thing is Medicare Part D Prescription Drug Coverage. Once you aren't covered by your employer's prescription drug coverage, you only have 63 days to purchase it to avoid the late-enrollment penalty.

[edinaman]

Two interesting things today. First, our friend's daughter in law was having a C-section today. My wife talked to her friend this afternoon to see how things went. It was rescheduled for this Saturday. It seems there was a problem with the insurance approval!! Maybe they should just wait until labor starts and see if her uterus ruptures. (Just being sarcastic).
Second, I talked to my derm's assistant today to tell her they needed to submit a Predetermination of Benefits. Her response was what is that, I've never heard of such a thing, and I'm the one who submits all the papers for insurance approvals. She gave me their fax number and told me to have BC/BS fax them whatever forms are necessary, and an explanation of what this is. The person I talked to today at BC/BS was very helpful and said she would send them the proper forms. It turns out, if the doctors doesn't know or isn't sure Medicare approves this drug, the submit this form and (of course) wait to hear if Medicare approves it. If they know Medicare approves the drug, they don't have to do this and we can proceed. My thought was, if the insurance company knew about this form, why didn't they, when the derm asked them for approval for this drug, find out if Medicare approves it? That's probably too logical. It looks like there is no way to avoid the $3000 co-pay, but I think we will be investigating other drugs that cost less.
Jeff

[Nik Colon]

Sorry for the issues. I can't remember if I said hi to you before or not so just wanted to say hi from Coon Rapids MN

[weisssoccermom]

Thanks Julie. I didn't know the timeframe but did know that while employed, you do not have any penalty regardless of your age. Funny about COBRA though. We were told that COBRA coverage wasn't considered to be "acceptable" coverage.