Community Chat

[gertrudecloset]

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@Silverfox1 wrote:

@gertrudecloset 

I forgot to mention that every 3 months out of pocket expenses of 20% in the amount of $374.00  I have to pay to my Neurologist for boxtox injections for severe migraines I have had since I'm eight years old. They help so I can't complain.

It use to be doctors would forgive the amount owed after the insurance companies paid them....not any more.

20% is eating us up alive but we don't really complain.  Most of the time, LOL!!  With all my health problems it must sound like I'm in pretty bad shape...but I happen to be doing just fine! At least acccording to ALL my doctors and tests, LOL!!!

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You got that right @Silverfox1 .  My doctor put me on a type of medication that is common for lowering blood pressure.  Same class of drugs that are usually prescribed but a different one that will work longer.  Guess what tier it's in?  A higher tier because they prefer that 50,000 pharmacies make the generic of the more common drugs.

Botox is likely a specialty drug.  Some insurance companies won't pay.  They most certainly don't pay for experiential therapeutic drugs either.  Then in the middle of a plan year they can switch up.  This is for them to save $$.  Insurance companies are money making businesses even though they have contracts with Medicare.

[gertrudecloset]

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@Carmie wrote:

@Silverfox1   It sounds like you have a Medicare Advantage Plan that is not very comprehensive.

I would suggest that you keep a list of your RX drugs you and your DH are taking, and during open enrollment starting in October have them checked by different plans to see if you could save some money.

AARP does not offer the best plans out there and they make money on the plans you buy that they represent.

I think you could do better if you make the effort. 

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No, it's not her Medicare Advantgage plan that's not comprehensive @Carmie .  It's the drugs she needs that typically are not covered by Part D and Medicare insurance plans.  Specialty Tiers.  Tier 1 have really low co pays compared to specialty drugs in a Tier 4, or 5 category.

Tier 1, 2 and even 3 is better than Tier 4 and 5 of a formulary.  Lots of meds are not covered. 

[gertrudecloset]

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@Silverfox1 wrote:

@Carmie 

I know our plan is awful however we have done exactly what you suggest for so many years and have gotten nowhere.  Like I said when Medicare opens up we call to check all plans but we are always told we have the best plan for us...case closed for that year.  Last time my DH called he was on the phone for more than 2 hours.  Could this be a Wisconsin problem?  I can't begin to tell how many people on Medicare in our State also have United Healthcare insurance with AARP.  Like us, we have Medicare and United Healthcare Ins.thru AARP.  I'm sorry I should have  made myself clear about all our insurance.

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United Healthcare through AARP?

If so, I used to have it.  I dropped them because every year they used to go up and move drugs around their formulary.  I don't mind paying a bit more, but the insurance companies can do what they want.  I sit down and factor in how many times and why I typically see a doc and if it's specialty or my primary.  That's how I determine an Advantage Plan.  All my docs need accept the plan too, because if it's an HMO sometimes they are strict and you can't go out of network @Silverfox1 

[gertrudecloset]

@NickNackProlia doesn't have a generic.  That's why it costs so much.  Ask your doc if there is something else you can take that is lower in cost and at least has a generic.  Prolia might be a "new class of drugs" and unfortunately if that's true, you will have to pay for it to benefit from it.

All these new drugs we see on t.v. are just that.  New.  They may get a generic in 12 years, they may not.  You can also apply to the drug company to see if they can help lower the cost.  This doesn't hurt.  I know some pharma companies do this...

Call 1 866-AMG-AAST Pharma company is Amgen...this will be income based.

[gertrudecloset]

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@Carmie wrote:

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@gertrudecloset wrote:

@Silverfox1  That's the point I was trying to make.  The Federal Government will get it's 20% for Medicare whether you pay it or a subsidy pays it.  That's a fact.  No one is getting their other 20% for free.

Your post is spot on.

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No one pays the Federal Govt 20%.  The 20% coinsurance is paid to the provider of the service and if you have a supplement, it will be paid by your insurance.  If you have no insurance except for Traditional Medicare, the patient will be billed for it.

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@Carmietrue.  I meant that they (Federal Government) will not give you more than 80%  That's it.  Periodt....if you are lower income you do get additional assistance to help you meet that 20% burden you will have.  That "additional assistance" is from taxpayers (from SSA or your State's Medicaid) that would mean it's not free.

[NickNack]

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@gertrudecloset wrote:

@NickNackProlia doesn't have a generic.  That's why it costs so much.  Ask your doc if there is something else you can take that is lower in cost and at least has a generic.  Prolia might be a "new class of drugs" and unfortunately if that's true, you will have to pay for it to benefit from it.

All these new drugs we see on t.v. are just that.  New.  They may get a generic in 12 years, they may not.  You can also apply to the drug company to see if they can help lower the cost.  This doesn't hurt.  I know some pharma companies do this...

Call 1 866-AMG-AAST Pharma company is Amgen...this will be income based.

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@gertrudecloset   I took a couple of other drugs for osteoporosis before starting the Prolia injection.  I had horrible side effects of joint pain.  They are common side effects for the other drugs.  Prolia is the best treatment for osteoporosis.  I did look at the program that Amgen offers, and it's not available for people on Medicare.  It's only available for people with private insurance.

I have taken Prolia for three or four years and only had to pay $100+ for each injection.  Since I only get it twice a year that's not bad.  It was only this time that they said they had paid out the maximum benefit for that drug.

[gertrudecloset]

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@NickNack wrote:

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@gertrudecloset wrote:

@NickNackProlia doesn't have a generic.  That's why it costs so much.  Ask your doc if there is something else you can take that is lower in cost and at least has a generic.  Prolia might be a "new class of drugs" and unfortunately if that's true, you will have to pay for it to benefit from it.

All these new drugs we see on t.v. are just that.  New.  They may get a generic in 12 years, they may not.  You can also apply to the drug company to see if they can help lower the cost.  This doesn't hurt.  I know some pharma companies do this...

Call 1 866-AMG-AAST Pharma company is Amgen...this will be income based.

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@gertrudecloset   I took a couple of other drugs for osteoporosis before starting the Prolia injection.  I had horrible side effects of joint pain.  They are common side effects for the other drugs.  Prolia is the best treatment for osteoporosis.  I did look at the program that Amgen offers, and it's not available for people on Medicare.  It's only available for people with private insurance.

I have taken Prolia for three or four years and only had to pay $100+ for each injection.  Since I only get it twice a year that's not bad.  It was only this time that they said they had paid out the maximum benefit for that drug.

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@NickNackI'm pleased to hear that for your sake.  I take certain steroids that are Tier 3 of my Drug Plan and the retail cost is $410.00, but I only pay $47.00 after I have met my deductible.

Glad you're ok NickNack!  Hey it may become generic one day.  It usually takes twelve years though after a drug has been granted FDA approval.

[Linmo]

@drizzellla Thanks for your initial post.  DH will be 65 in 2023 so we need to start thinking about this.  

@Carmie DH is employed by a large company.  We live in CA and don't expect him to retire for several years.  I retired when our kids were born 20+ years ago.  From what I've read on the Medicare website, he should sign up for Part A Medicare 3 months before his 65th birthday, but can defer Part B until he retires.  I am a year younger so assuming that the same applies for me a year after him.  

Thanks for all of the advice!

[Carmie]

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@Linmo wrote:

@drizzellla Thanks for your initial post.  DH will be 65 in 2023 so we need to start thinking about this.  

@Carmie DH is employed by a large company.  We live in CA and don't expect him to retire for several years.  I retired when our kids were born 20+ years ago.  From what I've read on the Medicare website, he should sign up for Part A Medicare 3 months before his 65th birthday, but can defer Part B until he retires.  I am a year younger so assuming that the same applies for me a year after him.  

Thanks for all of the advice!

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Yes, you can do this.  Just remember to get Part B when he retires.

another helpful hint....your DH should not give his Medicare card when he receives medical services.  It creates a lot of confusion.

[Carmie]

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@gertrudecloset wrote:

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@Carmie wrote:

@Silverfox1   It sounds like you have a Medicare Advantage Plan that is not very comprehensive.

I would suggest that you keep a list of your RX drugs you and your DH are taking, and during open enrollment starting in October have them checked by different plans to see if you could save some money.

AARP does not offer the best plans out there and they make money on the plans you buy that they represent.

I think you could do better if you make the effort. 

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No, it's not her Medicare Advantgage plan that's not comprehensive @Carmie .  It's the drugs she needs that typically are not covered by Part D and Medicare insurance plans.  Specialty Tiers.  Tier 1 have really low co pays compared to specialty drugs in a Tier 4, or 5 category.

Tier 1, 2 and even 3 is better than Tier 4 and 5 of a formulary.  Lots of meds are not covered. 

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People who have advantage Plans for the most part do not have plan d for RX coverage. Most are all inclusive There are a few Advantage plans out there where RX drugs  are not covered, but if you have one of those, your coverage is not comprehensive.