Worried about Herceptin on Medicare

illimae

Hi all, I’m due to be switched to Medicare in December by SSDI and my retirement plan (Employees retirement system of Texas) will then change me from BCBS to either Healthselect Medicare Advantage by Humana, which is out of network for MD Anderson (MDA) or healthselect secondary BCBS, which I’m told is not accepted at all by MDA.

Those of you on Medicare and receiving Herceptin every 3 weeks, is it covered? I’m concerned I’ll have to pay the remaining 20%, which would be several thousand dollars for each infusion.

I appreciate any Medicare/insurance tips.

MinusTwo

Mae - I am on standard Medicare Part B (not the Advantage plan Part C) and I can choose any docs or hospitals that I want. I have a medigap plan through AARP (United Health Care) that pays the balance - 20% that medicare does not pay. I chose this because I wanted to see who I wanted to see, when I wanted to see them, with no gate keepers.

That said, there are still lots of options if you go with standard Part B Medicare and a Medigap policy. For example - I pay no co-pay but I do pay my own deductible every year (around $190 per year). I have a friend who has a $10.00 co-pay at every appointment but pays no deductible. I'd guess there are at least 10 different choices. That said - I NEVER have had to pay a dime over my deductible for doctors, chemo, infusions, treatment, surgeries, scans, PET/CT, MRI, etc. I think that $1000 was the hospital deductible for Part A for the surgeries - but that may now have a time limit shorter than a year. I mean seriously - Herceptin for a year, Perjeta, second round of chemo with recurrence, podiatrist for lost toenails from chemo, neurologist for neuropathy. The only thing that is not covered is an MMR vaccine, which they didn't have when I was a kid & a few things like that. And dental & glasses are not covered.

Sounds like you're only considering an Advantage plan. I have friends who love the prices, but you are right - there are hospitals & docs that are always out of network. I didn't think there was a 20% deductible with an Advantage plan, but I could be wrong. If you have a nurse navigator at MDA, I'd ask about the two plans you are considering. Otherwise maybe call their business office. Usually people there really care. Or maybe the office manager for your doc(s). Be sure the docs you love will accept whatever plan you choose. One of the reasons for my choice was to have full access to MD Anderson when & if I need it.

Anonymous

In some states there aren’t any Medigap plans for people under 65 on SSDI so you might be forced to chose an Advantage plan.

You can check here to see what’s available for your situation

https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m

It sounds like your retirement plan pays for the two you mentioned, but maybe there are other Advantage OR Medigap plans you can pay for yourself, that include MDA in their network, listed on the site.

Also have you spoken to a financial counselor or social worker at the hospital yet? They usually know all about how to get your infusions covered

Spookiesmom

I have an Advantage plan from Humana and have been very pleased with it. Switched from regular Humana plan to this 8 years ago. $10 copay to specialist, $3.60 generic med. $0.00 for Ibrance. That’s 13 k a month. My MO office arranged financial aid for that. No deductible, no cap on spending Last year, with surgery and rads again, I hit catastrophe and didn’t have dr copays the rest of year

Your time frame is during open enrollment so I suggest starting now to talk to different insurance co about plans available in your area your hospital or MO office should be able to help too.

I still pay the monthly Medicare amount, 135? But that’s all. This isn’t a supplement where YOU pay a monthly premium in addition to everything else,

illimae

Thank you everyone. MDA does take Medicare, so my big concern is the IV Herceptin and Perjeta, which falls in the part B category covered at 80%. The pre-insurance price tag is about $46,000 per treatment (every 3 weeks) 20% is $9,600. Still gathering info but not finding any clear answers yet.