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Infusions/Medicare costs #282034 11/13/18 02:26 AM
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dixieagle Offline OP
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My husband and I will soon be on Medicare. He has been getting Humira through the Abbvie patient assistance program. I have a couple of questions:

1) I understand that the patient assistance program isn't available to people on traditional Medicare. Do any of you know if it's covered if you are on an Advantage plan, such as Blue Advantage?

2) An alternative would be an infusion drug, such as Remicade or similar. I think there'd be a 20% copay. Can you give me a ballpark figure as to what type of cost we'd be looking at? I'd seen a price of about $1200/infusion on some plans, so I guess we'd be looking at about $240/infusion out of pocket? Does this sound about right or am I being optimistic?

Any and all suggestions as to how to get the cost down are most welcome. The Humira is likely far too expensive without assistance, but infusions may be doable. Many thanks!

Re: Infusions/Medicare costs [Re: dixieagle] #282038 11/13/18 07:09 PM
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Banana Offline
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I have been on medicare for 8 years now. None of the patient assistance programs cover Medicare patients AND they know the minute you are on medicare. I recommend checking out AARP's medicare supplemental programs because you can call as many times as you want. They don't make you go on line, but do go on line to see what they offer. For minimal additional cost, I went on a supplemental that covers me everywhere in the US, with no copay and both my husband and I had hospital stays this year. Mine (including ambulance, ER, procedure and over night stay) cost $19. His was a same day procedure at a top hospital and his bill was $17. What I am saying is getting a higher end supplemental could save you a lot of money!!!!!

Unfortunately, unless there is an injection that has turned generic--they only cover the infusions. I would check with where you want to get your infusions to see the costs and which insurance they take. I get mine in the hospital and it is completely covered. I do not pay a dime. It is Actemra. A bit of a pain in the neck because I have to go every month 2 hour commute each way, so a whole day every month. BUT I am pretty much in remission so how can I complain?

Congrats on getting on Medicare, great insurance!!!

Last edited by Banana; 11/13/18 07:11 PM. Reason: forgot to mention no copay which can really add up, when you see a lot of doctors.

Actema IV once a month (with pre loading for allergic reaction), Cymbalta x1 daily, Arava 20mg daily. Diagnosed with AS in 2004, suffered undiagnosed since 1982.
Re: Infusions/Medicare costs [Re: dixieagle] #282040 11/13/18 08:02 PM
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RAHMBA Online
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Frankly, not sure why people are basically forced to change medications when they get on medicare. based solely on the way the medication is administered.

There are two IV medications indicated to treat AS: Remicade (infleximab) & Simponi Aria.

Remicade has been available for a long time. I believe it's typically taken every 6-8 weeks. There are biosimilars approved for Remicade.

Simponi Aria is the newest TNFi indicated for AS. typically given for 30 minutes, every 8 weeks.

Hope that helps,
Rich


AS, U C, Iritis, migraines. HLA-B27neg. Yoga (instructor) & spin. No meds at this time. Dx 1989. SAA member/donor since 1993. All my posts are personal opinion/feelings and do not represent the SAA. Help find a cure & support others by donating to the SAA.
Re: Infusions/Medicare costs [Re: dixieagle] #282041 11/13/18 08:32 PM
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Winston Offline
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Have you checked all of the Medicare Part D plans available to you in your state to see if any of them will cover Humira and at what price?

Here is what AbbVie advises Medicare patients:

Medicare is a federal health insurance program for people 65 and older and others with certain disabilities. With Medicare, it’s important to note that prescription coverage is available through many Medicare Advantage Plans (Part C), and Supplemental Plans (Part D)—but you must enroll separately.

Medicare Advantage Plans (Part C)

Medicare Advantage Plans are private insurance plans that provide Parts A and B Medicare coverage (hospital and medical insurance), and generally includes prescription coverage.

Supplemental Plans (Part D)

This is a separate prescription coverage option that you can add to Medicare Parts A and B. You must enroll in Medicare Part D.

People on Medicare who need help paying for their prescriptions may be eligible to receive a low income subsidy (also known as LIS or Extra Help).

To find out if you’re eligible, there are three ways to apply:
Online at www.socialsecurity.gov/extrahelp
Call Social Security at 1.800.772.1213 (TTY 1.800.325.0778)
At your local Social Security Office

If you're not eligible, HUMIRA may still be available at no additional cost. Please call 1.800.4HUMIRA (1.800.448.6472) to talk to one of our Insurance Specialists for assistance.

https://www.humira.com/humira-complete/insurance-coverage-explained

Re: Infusions/Medicare costs [Re: RAHMBA] #282042 11/13/18 09:36 PM
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I believe some Medicare Advantage plans and some Medicare Part D drug plans do cover Humira. You would have to check the details of various plans to find the best plan for you. Medicare.gov has an online tool that can be used to help find a plan based on where you live and what drugs you take. You can also ask your local insurance agent if they can help you find the best plan, or can refer you to someone else who can.

I would also suggest you talk to the pharmacy that provides his Humira.They deal with insurance companies every day and should be able to give you some general information based on what they have seen with their customers.


Ginny - 58 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis, both currently in remission
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Infusions/Medicare costs [Re: dixieagle] #282049 11/14/18 05:06 AM
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dixieagle Offline OP
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Thank you all for responding.

We are working with a Medicare specialist familiar with both traditional supplements and Advantage plans. From what we've seen so far, Humira is "covered" but the co-pay is absurdly high. We'd heard that in some instances, folks on Medicare can continue to be eligible for patient assistance programs, but I haven't yet found any of those instances that might apply to us.

It appears that Remicade infusions would cost, with co-pay, about a quarter of the cost of Humira. While not cheap, about $298 every six weeks certainly beats about $1150/month. Banana - I am intrigued by the fact that you pay nothing at all for your in-hospital infusion. We've seen 20% co-pays, but nothing that would be totally free.

My husband will talk again to the AbbVie folks, but I'm afraid that ship will sail the minute we are officially enrolled in a Medicare plan. I am relieved to know about the possibility of infusions.

Re: Infusions/Medicare costs [Re: dixieagle] #282053 11/14/18 03:07 PM
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Originally Posted by dixieagle
We'd heard that in some instances, folks on Medicare can continue to be eligible for patient assistance programs, but I haven't yet found any of those instances that might apply to us.


Folks on Medicare are eligible for the patient assistance plans based on income, but not for the co-pay assistance plans. Medicare.gov tells you what programs are available to Medicare users. Go to the following link and navigate your way to the Humira-related plans. https://www.medicare.gov/pharmaceutical-assistance-program/

Here's a brief explanation of why Medicare patients can't take advantage of co-pay assistance plans or coupons: https://www.npr.org/sections/health...patients-use-drugmakers-discount-coupons

As for Anna's situation, she probably has a Medicare supplement. My husband is on Medicare with a supplement through Blue Cross. The only medical costs he pays per year (other than drugs, for which he has a separate Part D plan) is the Medicare deductible, which was $183 for 2018 and will be $185 for 2019. My husband has a lot of health issues, so we would have tremendous costs if he were using only Medicare without the supplement.


Ginny - 58 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis, both currently in remission
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
Re: Infusions/Medicare costs [Re: dixieagle] #282055 11/14/18 05:44 PM
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Banana Offline
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No, there are no instances except for VERY low income where medicare people can have access to patient assistance programs. Do not waste your time. Usually when you get that poor, you switch to medicaid.

Yes, everyone should have an supplemental insurance and it is worth every penny. I pay no co pays for visiting doctors and I see 6 different kinds of doctors and several every other month.


Actema IV once a month (with pre loading for allergic reaction), Cymbalta x1 daily, Arava 20mg daily. Diagnosed with AS in 2004, suffered undiagnosed since 1982.
Re: Infusions/Medicare costs [Re: Banana] #282056 11/14/18 07:01 PM
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dixieagle Offline OP
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Originally Posted by Banana
No, there are no instances except for VERY low income where medicare people can have access to patient assistance programs. Do not waste your time. Usually when you get that poor, you switch to medicaid.

Yes, everyone should have an supplemental insurance and it is worth every penny. I pay no co pays for visiting doctors and I see 6 different kinds of doctors and several every other month.


We will absolutely choose either a Plan F or, more likely, Plan G plus Part D, or a Medicare Advantage plan (likely Blue Advantage here.) Our Medicare specialist is sorting through the various options, taking the Humira or a similar infusion drug into consideration. Banana - I am intrigued by the fact that you pay no co-pay for your infusion; I was pretty sure we'd have a 20% co-pay. Maybe I'll be pleasantly surprised (or maybe he'd just have to have it done in the hospital instead of outpatient at the doctor's office...)

At any rate, it sure sounds as if any AbbVie assistance goes away.

Re: Infusions/Medicare costs [Re: dixieagle] #282058 11/14/18 10:32 PM
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Originally Posted by dixieagle
I am intrigued by the fact that you pay no co-pay for your infusion; I was pretty sure we'd have a 20% co-pay.


It probably depends on which plan you end up with. My husband's Medicare Supplement plan covers all co-pays. It sounds like Anna's does too.

Quote
(or maybe he'd just have to have it done in the hospital instead of outpatient at the doctor's office...)


I'm guessing this will probably be the case. Seems like I read somewhere that Medicare only covers infusions in hospitals or specialized infusion clinics. But I don't remember where I read it and I could be wrong. Maybe your Medicare specialist knows or can find out.


Ginny - 58 year old female
Dx with USpA in March 2013; changed to AS in July 2015
Iritis and Scleritis, both currently in remission
unicompartmental knee replacements: right-June 2014, left-Aug 2018
MTX, Humira, Cyclobenzaprine, plus Celebrex as needed
Supplements: Folic Acid, Vitamin A, Vitamin D, Calcium, Fish Oil, Culturelle probiotic, Melatonin (as needed)
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