Humira or Enbrel injections - cost to MAPD members?

I know it is 20% of the Medicare approved amount but I need an answer in dollars. I am sure I have clients getting one or the other but I only hear about problems. If the 20% was HUGE, I am sure I would hear about it. Anybody?
 
I know it is 20% of the Medicare approved amount but I need an answer in dollars. I am sure I have clients getting one or the other but I only hear about problems. If the 20% was HUGE, I am sure I would hear about it. Anybody?

Humira is Part D - not B. At least from everything I've seen....

Not sure on Enbrel, but I believe it's Part D as well.
 
Humira and Enbrel are both Part D. Clients on either of those will see both the coverage gap and catastrophic coverage. If Remicaid or one of the other in office infusions is an option (I’m told by my mother and multiple clients that they work better), then a supplement will cover them. The cost is going to be dependent on the Part D coverage. Any in office infusions are going to be 20% on original Medicare or most MAPD options and the dollar amount depends on what the provider charges.
 
Drugs Covered by Medicare Part B
Prescription Drug Coverage

I'd also recommend going to www.goodrx.com and typing Humira and Enbrel. Once you've done that click on the Savings Tips tab and check out the Manufacturer Coupon and Patient Assistance Programs along with the other tips they give. This could possibly save them big if they qualify. Keep in mind that just because a person makes a little bit more in income or is on a MAPD or PDP doesn't automatically disqualify them from help with some of these programs. I have found some big savings for people through here. I.e. One person I helped got a $1,500 a year rebate on Prolia.

Do something unexpected for someone that helps them out and saves them a lot of money (especially on their prescriptions) and they could be a client for life, and feed quite a few referrals your way as well.

Hope this helps.
 
Justintime,
Most of these discounts from the manufacturers that I have seen do not work with any govt program, here is a bullet point from Amgen's site -
  • Must not be a participant in any federal-, state-, or government-funded healthcare program such as Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD), or TriCare
I would love to be wrong about this because it would be great for many of my clients.

I see a lot of "mice type" on tv commercials and notice one last weekend that said it could not be used with Medicare.
 
Justintime,
Most of these discounts from the manufacturers that I have seen do not work with any govt program, here is a bullet point from Amgen's site -
  • Must not be a participant in any federal-, state-, or government-funded healthcare program such as Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD), or TriCare
I would love to be wrong about this because it would be great for many of my clients.

I see a lot of "mice type" on tv commercials and notice one last weekend that said it could not be used with Medicare.
This seems to vary from one pharmaco to another. I have seen it both ways. My client on a $13,000 a month Rx for cancer treatment after using up chemo and radiation was distraught, until we called the mfg and client was given 100% paid benefit. It was income related. I have seen 200% to 500% of poverty level as a measure, varying degrees of help by income and manufacturer.
 
Phyllis is correct. It varies widely from manufacturer to manufacturer.

Some say if you are on Part D you are ineligible. Others say if your plan formulary does not include the drug you may qualify. Others consider how much the drug costs and may subsidize your Part D copay.

Everyone I have seen does have some kind of income requirement.

Before Part D more folks could qualify for PAP subsidies. Now the number of eligible participants is considerably lower
 
I try to use this site when possible - I used it today with one of my MAPD clients to look up one of her individual Rx's.

She doesn't qualify for LIS because she and her husband's combined income is above the threshold. However, that doesn't make Jardiance cheap.

So, I looked up Jardiance on here and there is possible assistance for her if she has Part D but doesn't quite qualify for the LIS. I gave my client the info and hopes she can get some help - instructed her to call Boehringer.
 
Justintime,
Most of these discounts from the manufacturers that I have seen do not work with any govt program, here is a bullet point from Amgen's site -
  • Must not be a participant in any federal-, state-, or government-funded healthcare program such as Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD), or TriCare
I would love to be wrong about this because it would be great for many of my clients.

I see a lot of "mice type" on tv commercials and notice one last weekend that said it could not be used with Medicare.

Interesting note on Amgen specifically, the client I referenced above that I'm trying to get her help on Jardiance has been getting Enbrel free of charge for several years - and I had in my notes from 2016 that she was helped by the Safety Net Foundation - which is an Amgen program.

They must make exceptions since she's been getting help from them since at least 2016.
 
As a side note, I read an article last couple days about Narcan getting increased by several hundred percent, and the interesting math around the increases, including setting money aside for those without coverage that pays most of the cost. As if somehow all of us don't wind up paying for the increases. When an insurance, say employer or ACA based plan pays most of the cost, it just gets passed back. Taxes or premiums.
Anyone see Fight Club, basically a story based around an insurance/risk management decision process where the young man in charge of executing the decisions from above about how many people had to die before manufacturer's defects were repaired went insane. Brad Pitt/Ed Norton. Takeaway, the first rule of drug pricing decisions, we can't talk about drug pricing decisions. Dark humor gets me by some days.
 
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