Crohn's Disease Forum » Treatment » Stelara/Ustekinumab » Medicare Coverage for Stelara


11-15-2018, 02:15 PM   #1
Scipio
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Medicare Coverage for Stelara

Has anyone found a Medicare Advantage or Part D plan that provides good coverage for Stelara?

The drug so far is working well for me, so I would rather not switch. And I'm currently employed and on the Janssen CarePath coverage, which is great -- only a $5 co-pay per dose. But looking ahead I'd like to retire in the next year or two so I'm starting to shop Medicare plans. And Medicare insurance is not eligible for the CarePath program.

So far a cursory search has shown me that more than half of the companies out there don't cover Stelara at all. And the ones I've found that do cover it only partially, and thus they require a hefty co-pay. I recognize that I will have to pay more than $5 per dose out of pocket, but I'm hoping not to pay thousands per dose. So if anyone has found a Medicare drug coverage plan that does a decent job of covering Stelara expenses please post it up.

Thank you.
11-15-2018, 02:38 PM   #2
my little penguin
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Look at the “doughnut clause” the range you pay more
It’s where you pay more out of pocket until you hit catostrophic value
Then no copay afterwards
What the “doughnut value “ is as well as the catostrophic value can really impact your copay
This starts over every single year unfortunately

You may want to look at medical assistance
Under ssi
Most Crohns patients qualify and then medical assistance does cover all of Stelara
As well as other critical things for Crohns patients


Ds is only 14 so no help on which Medicare covers Stelara
But medical assistance does cover Stelara
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11-17-2018, 02:54 PM   #3
trebor-HI
 
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I also am trying to understand what if any medicare coverage exists for Stelara. I'm 62, so I'll need to figure this all out over the next couple years. As far as I can tell, the medicare advantage and part D drug coverage plans offered by the company I retired from, does not cover Stelara. Gulp...
Not sure but I think biologic treatments administered by infusion are covered by Medicare Part B.
I'l be following this thread with great interest and will post anything I learn.
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Trebor

diagnosed with Crohn's 2012
Apriso, buedesonide, imuran, prednisone, humira, methotrexate and Stelara.
No surgeries, but hospitalized four times due to small bowel obstructions.
11-20-2018, 11:12 AM   #4
Scipio
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Looking around on the Medicare.gov and insurance company websites. It looks like you can get Medicare coverage for Stelara on more than a dozen different plans here in the San Diego area. The cheapest is Kaiser for a about $6K/year for the full insurance package, but of course you have to go to Kaiser doctors, which for me would involving switching doctors.

The most expensive ones run about $12K/year with about $10K of that being for the Stelara and the other $2K for the rest of your Medicare insurance. The middle of the road plans run about $9K - $10K/year with about $8K of that being for the Stelara.

Stelara is a pretty good drug, but even with insurance it sure ain't cheap.
11-20-2018, 12:59 PM   #5
Scipio
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Also, all of the Medicare plans I was able to find that would cover Stelara are HMOs. If you had your heart set on a PPO you are out of luck, at least in the San Diego area. Not sure about other parts of the country.
12-05-2018, 02:33 PM   #6
dynomite
 
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We aren't experts in Medicare by any means. My wife uses Stelara and could not find a medicare part D plan that would cover it.

I hope that you have better luck.
03-01-2019, 09:22 AM   #7
trebor-HI
 
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We aren't experts in Medicare by any means. My wife uses Stelara and could not find a medicare part D plan that would cover it.
gee, are you paying full price for Stelara...out of pocket? I'm on Stelara and turn 65 in about two years. Wondering what to expect...
03-01-2019, 12:31 PM   #8
my little penguin
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Each state is different but when Medicare doesn’t cover a drug
If you call the state they can tell you what “extra plans” they offer - different cards that are made to cover drugs for older adults
03-11-2019, 02:46 PM   #9
GI Jane
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Looking around on the Medicare.gov and insurance company websites. It looks like you can get Medicare coverage for Stelara on more than a dozen different plans here in the San Diego area. The cheapest is Kaiser for a about $6K/year for the full insurance package, but of course you have to go to Kaiser doctors, which for me would involving switching doctors.

The most expensive ones run about $12K/year with about $10K of that being for the Stelara and the other $2K for the rest of your Medicare insurance. The middle of the road plans run about $9K - $10K/year with about $8K of that being for the Stelara.

Stelara is a pretty good drug, but even with insurance it sure ain't cheap.
Tricare does, but unless you or your spouse is military I guess that doesn't help. I'm going from Vedo to Stelara next month so praying this one works without horrible side effects like I had from Remicade and Vedolizumab. Love your picture. Was in Rome last year, almost died from heat in the Colosseum and that was in April, well maybe beginning of May. Wouldn't you would have loved that communal toilet the tour guide showed us that was there that was a funny story. A picture of it in the link below and some of the intel the guide gave us that day. Take care.

https://www.sapiens.org/column/curio...man-bathrooms/
03-12-2019, 11:53 AM   #10
Scipio
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Yes, I love Italy in general and Rome in particular. Italy is my favorite European country. I have visited about 5 or 6 times (and I saw the public toilets).
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