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Medicare Coverage for Stelara

Location
San Diego
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.
 

my little penguin

Moderator
Staff member
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
 
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.
 
Location
San Diego
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.
 
Location
San Diego
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.
 
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.
 

my little penguin

Moderator
Staff member
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
 
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/curiosities/ancient-roman-bathrooms/
 
98% of Medicare Part D plans cover this drug. However if you do decide to switch to a different plan I recommend switching to Plan F. This has been the most popular Medigap plan. The reason is that Medigap Plan F provides the most complete coverage when comparing all of the Medigap supplement plans. So your drug will definitely be covered and it's also an ideal plan for seniors. In general, I recommend reading the article on https://www.remedigap.com/companies/mutual-of-omaha-medicare-supplement/ to make sure which plan works best for you.
 
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I am on Medicare and also have United Health care plan. My plan covers Stelara but copay is $3,326. I applied for help thru Johnson and Johnson but have not heard back yet. What I do know is that J&J financial help only helps with the injections but not the loading dose by IV infusion.

Is there someone else on Medicare and how did you manage the loading dose cost? I know the infusion center is covered by insurance but is there help out there for the cost of the loading dose?
 

my little penguin

Moderator
Staff member
So loading dose is an infusion so that falls under the medical side of insurance …
No different than if your inpatient / outpatient and having a procedure done
The Stelara med given by iv is just part of the infusion procedure being done as well as Benadryl/solumedrol if given during the procedure
So talk to the medical side of insurance

Completely different than injections which go through the prescription side of things
 

Lynda Lynda

Member
Location
Arizona
So loading dose is an infusion so that falls under the medical side of insurance …
No different than if your inpatient / outpatient and having a procedure done
The Stelara med given by iv is just part of the infusion procedure being done as well as Benadryl/solumedrol if given during the procedure
So talk to the medical side of insurance

Completely different than injections which go through the prescription side of things
Someone help me. 😳
I am trying to get financial assistance for my Stelara Infusion. I have had 3 conference calls with UHC, JJPAF and myself.
The JJPAF ( Johnson & Johnson Patient Assistance Foundation ) representative has verbally told the UHC representative what paperwork to send to me so that I can fax that paperwork to JJPAF.
My Stelara Syringe has already been approved at JJPAF for complete financial assistance thru the end of 2021.

Should I call the UHC Corporate Office ?

I was diagnosed with a Crohn's flare in March / April 2021. I took Prednisone for a month, then started Budesonide, MTX and Folic Acid in May 2021. My Humira has quit working so I need Stelara.

The End
 
Location
San Diego
As My Little Penguin points out, the loading dose infusion is a medical procedure and thus is covered under your medical plan and not under your prescription drug plan. When I got my loading dose there was no separate charge for the drug that was infused. It was all rolled into the fee for the medical infusion procedure.

Since your post-loading injections have been approved, it looks like your GI has submiited a pre-authorization for the maintenance doses of drug under your drug plan. Has s/he also submitted a pre-authorization for the infusion procedure? If not, that's what needs to happen next.
 

Lynda Lynda

Member
Location
Arizona
As My Little Penguin points out, the loading dose infusion is a medical procedure and thus is covered under your medical plan and not under your prescription drug plan. When I got my loading dose there was no separate charge for the drug that was infused. It was all rolled into the fee for the medical infusion procedure.

Since your post-loading injections have been approved, it looks like your GI has submiited a pre-authorization for the maintenance doses of drug under your drug plan. Has s/he also submitted a pre-authorization for the infusion procedure? If not, that's what needs to happen next.
Now I have to admit that I was wrong while talking to UHC today 😣

The UHC representative today mentioned a pre-authorization !

So, my GI must send a pre-authorization to United Health Care ?
Would my GI have that fax # for UHC ?
Why doesn't my GI and his MA know how to do this for Stelara.

I get so mad at people on the phone.

Thank You for explaining how it works. 🌼
 

my little penguin

Moderator
Staff member
It depends on if you need a prior authorization…
My insurance does not require a prior authorization for infusion meds IF the drug being used has been fda approved for the dx code entered by the Gi

That said most insurance companies require prior authorization.
The back of your insurance card or the website should have the number for the prior authorization to be faxed to
 
So, I finally made 65 years old May 2021. My insurance was such that both the initial dose administered by infusion and the maintenance doses administered by subcutaneous injection were covered by my medical plan vs my drug plan. This was the case with the commercial plan I had prior to turning 65 and the Medicare Advantage Plan I enrolled in after turning 65.

That all changed October 15 when Medicare added Stelara to the "self administered drug" exclusion list. My existing drug plan, which is not part D, does not cover injectable medications. So currently, I no longer have coverage for Stelara. My provider was kind enough to turn-over a sample provided to them by a pharmaceutical company to get me through the end of the year.

So, I'm looking at a particular MAPD plan offered through the company from which I retired. Stelara is in its Oct 1 2021 formulary but not sure if it is listed as a drug plan benefit or a now defunct medical plan benefit.

If a drug plan benefit, there is a confusing set of rules to determine the copay. I understand that MAPD plans must meet a minimum co-pay standard establish by Medicare. So some plans are better than the medicare standard. For my particular plan the copay is 33% during the Initial Coverage Stage, 25% during the Coverage Gap Stage, and 5% during the Catastrophic Stage. The coverage gap thresholds are $4,430 and $7,050 which is apparently the medicare standard threshold values. My plan description includes the footnote "After beneficiary's yearly out-of-pocket drug costs reach $7,050*, beneficiary pays the greater of 5% coinsurance or $3.95* copay for generics and $9.85* copay for all other drugs.
The asterisk * - CMS Mandated Changes for 2022

Still lots of questions...but if the retail cost per injection is $15,000 and I get six injection per year, my total out-of-pocket would be $10,800....I think, haha.
 
"Retail cost varies by specialty pharmacy. It’s close to $23000 per shot right now per the drug insurance claims for my kiddo on Stelara every 4 weeks"

I've had 20 injections thus far all administered by a hospital infusion center and billed to my medical plan. I built a spreadsheet of all the various cost data presented in the "Explanation of Benefits" documents. The infusion center pharmacy has billed the insurance Co. between $6,000 and $11,000 for the Stelara over the course of the 20 injections that I've had since 2018. The contract price between the provider and the insurance co has ranged from $3,900 to $7,000 while I was covered by a commercial plan prior to turning age 65.

Turns out the infusion center pharmacy purchases the Stelara from a drug wholesaler, hence the "low cost". I had considered the use of a specialty pharmacy at one time but they also were throwing around the $20k+ number. What a racket!

The damnedest thing is that since being on a medicare advantage plan, the insurance company is paying the provider more than they billed. Apparently something to do with medicare...
 

my little penguin

Moderator
Staff member
We are forced to use a specific speciality pharmacy per the commercial insurance-tried to get it through medical side by using infusion center for injection
Commercial Insurance refused to permit it .
Have to use the prescription insurance and specialty pharmacy per their rules
 
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