Client Has Rheumatoid Arthritis

[pahealthquotes]

This client suffers from RA and takes Enbrel 50 Mg/Ml (0.98 Ml) Sub-Q Syringe weekly. A few formulary searches list this as a speciality drug. Do most people who suffer from RA goto the doctors for IV or do most take weekly injections at home. How would this impact the cost of the medication?

She will be 65 in August so MAPD and Medigap with seperate part D is available to this client. She resides in Western PA.

Any help is appreciated.

 

[abcsales]

supp all the way. Had a guy call me and the MA plan wanted to charge him 1,200/month for the IV infusion, put him on the supp and it was paid for.

 

[Todd King]

The real difference here is if the injection is done in the Dr.'s office on not. If it's an office visit, then she'll be golden. If she does it herself at home, she may see hefty copays for that drug.

 

[riskybiz]

You also need to check with the Drs. office. Depending on which Pharmacy they use the DR may be required to buy and bill. I had a situation where the Pharmacy would not bill Medicare and the Provider refused to prepay.

 

[senior-advisor-indiana]

The real difference here is if the injection is done in the Dr.'s office on not. If it's an office visit, then she'll be golden. If she does it herself at home, she may see hefty copays for that drug.

Not really. If they go to the doc to get the shot and she is on an MA plan there is usually a 20% coinsurance on those plans. That is in Indiana. I have no idea how they are structured in PA.

 

[jacobtn]

Not really. If they go to the doc to get the shot and she is on an MA plan there is usually a 20% coinsurance on those plans. That is in Indiana. I have no idea how they are structured in PA.

You are correct, that's how it is here as well. Same applies for folks on oxygen, they have to pick up 20% of approved charges on MA plans, where supps pay the 20% so they pay zero.

 

[sman]

This client suffers from RA and takes Enbrel 50 Mg/Ml (0.98 Ml) Sub-Q Syringe weekly. A few formulary searches list this as a speciality drug. Do most people who suffer from RA goto the doctors for IV or do most take weekly injections at home. How would this impact the cost of the medication?

She will be 65 in August so MAPD and Medigap with seperate part D is available to this client. She resides in Western PA.

Any help is appreciated.

The general rule of thumb is if the medication is purchased at the pharmacy and self administered, then it would run through Part D.

If it is administered by the doctor/nurse, it is usually covered on the medical portion of whatever insurance a person has.

As for your other question about whether folks tend to self inject or go have an infusion (IV) treatment using some other medication, that is usually dependent upon the doctor and the patient. With that said, if the Enbrel works for this person, there probably won't be a reason to change medications and she will hit the donut hole fairly quickly due to the cost of Enbrel. If she wanted to have Medicare pay, she could talk to her doctor about switching to something like Remicade. It is administered through an IV at a medical facility. In most cases, Medicare would cover 80% of the cost and a Med Supp would pay the other portion.

I would recommend you advising this client of the potential cost associated with using Enbrel (just run a comparison on the Medicare website - that particular dose runs about $2,200-$2,300 retail per month) and see if she can have a discussion with her Rheumatologist to see if there might be another medication they can try. Otherwise she will hit the donut hole in the 2nd month and the catastrophic phase after the 3rd month.

One last thing, if she can switch to something like Remicade, a Med Supp is definitely the best way to go.

 

[senior-advisor-indiana]

The general rule of thumb is if the medication is purchased at the pharmacy and self administered, then it would run through Part D.

If it is administered by the doctor/nurse, it is usually covered on the medical portion of whatever insurance a person has.

As for your other question about whether folks tend to self inject or go have an infusion (IV) treatment using some other medication, that is usually dependent upon the doctor and the patient. With that said, if the Enbrel works for this person, there probably won't be a reason to change medications and she will hit the donut hole fairly quickly due to the cost of Enbrel. If she wanted to have Medicare pay, she could talk to her doctor about switching to something like Remicade. It is administered through an IV at a medical facility. In most cases, Medicare would cover 80% of the cost and a Med Supp would pay the other portion.

I would recommend you advising this client of the potential cost associated with using Enbrel (just run a comparison on the Medicare website - that particular dose runs about $2,200-$2,300 retail per month) and see if she can have a discussion with her Rheumatologist to see if there might be another medication they can try. Otherwise she will hit the donut hole in the 2nd month and the catastrophic phase after the 3rd month.

One last thing, if she can switch to something like Remicade, a Med Supp is definitely the best way to go.

I reported your post for being too thorough and for the lack of a smart ass comment...

 

[sman]

I reported your post for being too thorough and for the lack of a smart ass comment...

My bad. I had a brief moment of clarity. I'll try and not let it happen again.

May I call you Richard Cranium?

 

[senior-advisor-indiana]

My bad. I had a brief moment of clarity. I'll try and not let it happen again.

May I call you Richard Cranium?

That's much better.....