Medicare

[kurtflies12]

I'm turning 65 in September and was wondering if my Humira will still be covered under Medicare> My understanding is that the drug is close to 1500 per injection and thats a lot of bananas . Has anyone already been thru this? What were the results?
Thanks

 

[Clash]

I'm sure someone will be along with their experience.

My Mom and Dad have medicare and my Mom has RA. Her rheumatologist chose remicade over humira because remicade fell under the medical side whereas humira fell under the prescription plan side so it cost more out of pocket. This was a few years ago so things may have changed since then on how medicare handles it.

 

[kurtflies12]

Thanks Clash. We'll see if I'm the only one that is 65 on medicare and takes Humira.

 

[Poached Pear]

Hi,

There are 3 parts that you need to know about that together make up medicare coverage.
Part A is hospital coverage for inpatient stays and treatment. This is automatic and you you don't have to pay anything.

Part B is outpatient care including testing. You qualify for this when you turn 65 years old or you have been determined to qualify for disability. There is a monthly cost. If you do not sign up for this when you become eligible, there is a penalty (you will have to pay more when you do sign up).

Part D is prescription coverage. This is bought privately. There is no penalty for not having coverage.

You will need to find out if Medicare covers Humira under the medical benefit (part B) or under the drug benefit (part D). Some drugs that are infused are covered under part B. If it is covered under part D, then look on Medicare.gov at the various plans available. You can "shop" the various part D plans to see which will give you the best coverage - the cost you have to pay vs. the cost of the drug. You will also have to buy part B coverage which is general outpatient coverage - this is around $110/month.

The other option is a Medicare managed care plan. These look cheaper and have the drug benefit rolled in. They are best for someone who doesn't have a lot of care needs, and someone who is not looking to be on a specific medicine. They can be very restrictive in terms of their drug formularies and they also require more prior authorization and self advocacy for care. Their goal is to "manage" care which is really saying they are looking to manage cost. Personally, if you can afford it, I would not choose a medicare managed care plan (they are managed by commercial entities like United Health Care but their benefits look very different from the commercial side).

Hope this helps

 

[kurtflies12]

Have you been thru this yourself?

 

[Clash]

Since Humira is a shot, self injection it doesn't qualify as an infusion like remicade which is an infusion given by IV in an infusion lab at a hospital, GI office or infusion center.

This might help answer your question

Humira is a prescription medication and would not be covered by Original Medicare (Part A & Part B) nor your Medicare supplement plan F. It would be covered by a stand-alone Part D prescription drug plan if it is listed in the plan's formulary (list of drugs covered by the plan).

If your current plan doesn't cover the prescription, you can change to a different Part D plan (one that covers the drug) during the annual enrollment period (Oct 15-Dec 7 of each year).

Ugh it won't let me copy the link on my mobile but if you Google humira and Medicare you'll find several sources that can provide this information.

 

[lenny]

I know a healthy young man who is unemployed atm and just got on medicaid. And I got to thinking..if a healthy 20 something can get on medicaid, my son who has Crohn's should be able to when my husband retires and he loses that healthcare..

Or is medicaid any good?

We have been planning to purchase health insurance for our son, for life..

 

[Poached Pear]

I am a medical social worker. I still hate insurance and anything to do with it. I am just good enough to be competent. Not great. I'd much rather talk to people about feelings related to chronic illness or how to manage siblings that aren't affected, or how to make quality of life better for anyone. Without healthcare, you can't manage illness very well or have a good quality of life. So, I have to know something. And as a social worker I am obligated to be competent in my work.

 

[Poached Pear]

Humira may be covered under part B if you buy a Medicare managed care plan. Even if it is self infused. If you don't see it on the formulary ask if it is covered under part B. Sorry to be a wise you-know-what but this is my bread and butter. I do this everyday. Also, as with anything that is not covered you can always ask for prior authorization or appeal. Your doctor's office staff will likely be familiar. You can ask them for help too.

If you go to a hospital based practice ask for a referral to a medical social worker.

Now to Medicaid. Medicaid is different in every state. It is subsidized by the Federal Government but is State run. So depending on your State, the benefits will be different. If your son can work, I would say that other insurance is generally better. Also, if you get Medicaid you may be limited in the amount of income you can bring in and still maintain your insurance.

You can buy insurance through the Affordable Care Act (Obamacare). There is a "sweet spot" in the ACA where you earn between $11,500 and $46,000 and qualify for tax credits so that you basically don't have to pay for insurance. You would still need to pay for copays and deductibles but you are a working person (and there are mental health benefits to working if you can) and also the insurance is generally better than Medicaid. Which you have to qualify for, and sometimes requalify for, and if you are in remission, you may lose your benefits if you are well.

Of course you can stay on your parents insurance until you are 26 years old and some exceptionally wonderful companies have allowed patients of mine to stay on the parents insurance through COBRA for additional years.

 

[Clash]

Poached Pear it is so awesome to have some one of your position on the forum! I have some questions too. First regarding the managed medicare. The insurance specialist told my Mom that wasn't the perfect plan for someone with chronic illness since the formulary is restrictive and meds can change fast. Nor was it a good fit if frequent care was needed. She shied away from it due to the restrictive formulary list. Would this have been how you described it?

Second, right now my kids fall under our insurance and it covered til 26 even before ACA. It's a really great policy that had no premium until ACA passed, now it's 50 a month for the whole fam. Low deductible, no co pay, low out of pocket max blah blah blah. My daughter graduates next year and will be seeking employment as a teacher. We'll keep her on ours along as possible but I hear teachers in our state discuss how rotten their insurance is so is it then feasible to weed through all the ACA policies for her? Being a first year teacher maybe even a policy that falls in that sweet spot range you mentioned!

Thanks for the info you have supplied! I'm sure it will be helpful for many!

 

[Poached Pear]

Hi Clash,
Yes, this is exactly how I would describe the managed medicare. It is really for someone who is healthy. They have lures like help with transportation and the fact that you don't have to go out and buy a part D plan, but they are more difficult to work with. Because of the restrictions in the formulary, and all the prior authorizations required. They can work for some people, say, you find Humira is covered under a managed medicare plan. It may be worth it to go with it, it is a bit of a gamble but you know your drug will be covered. Just watch to find out what copays will be. Know that you will have to have a lot (more) contact with your doctor's office. If your doctor is part of an academic practice (hospital based) with a medical social worker who can help you, it can work. It is just a lot more work. And if you can afford the regular Medicare with the part B and D supplements, it may be easier.

If someone tells you a drug is not covered look for it someplace else in the plan. Is it covered under part B, can you get a prior authorization or appeal. I write letters of appeal for patient all the time. I am a nurse too so I can speak the language of these people who are telling patients, "no." Also, the doctor I work with is wonderful and he will sign most anything that I put in front of him. I do not work in the IBD field though. I work in a different medical specialty.

If your daughter is eligible for insurance through her workplace she is not eligible for the ACA. Many teachers have good insurance through their unions. Maybe contact the CCFA chapter in your area and ask if they know of any teachers who can provide information (who would be willing). I'm not sure if you can keep her on your plan and have her get insurance though her place of work. She would have a primary insurance and a secondary one. But I am not sure about this. Ask your HR. With 2 insurances you would likely have some pretty good coverage for a few years. She would have the time to find out about what districts offer the best benefits and get some experience. She could possibly transfer to a better district for health insurance. Or find out that her insurance really isn't bad at all. Or get married to someone who has awesome insurance (like it sounds yours is).

Teachers (good ones) rock!!!

 

[Clash]

She's my non-INDIVIDUAL kid my IBD kid starts college this fall and truly, honestly I can't yet fave the anxiety I have with him and insurance once he is off our plan at 26!

Georgia is a right to work state so unions aren't as strong here. I have a lot of teacher friends and have been picking their brains about their Insurance choices within their state insurance and why they chose each one.

Thanks so much for all of your info.

My Mom and Dad could afford the choice with plan D and chose it. I just wanted to make sure that the managed part they were explained fit what I read in case that may have been a better option but I don't think it would've been. Thanks so much for your help.

 

[Poached Pear]

Your mom and dad chose well (I think). I think those advantage plans (managed care) are a bear to work with.