Injectible Part D or B?

[yorkriver1]

Client meeting soon, and manufacturer offers to pay 100% while no insurance in place, this insured was referred to me after glitch, not enrolled in Medicare for 12/1/17 when T65, then kicked out of ACA coverage back to 1/1/18. They called me on 2/1/18 instead of 1/31, so no insurance or Medicare until 3/1.
When there is insurance, the manufacturer says they will help for Rx not covered on Part D. If the injectible is covered by Part B and they purchase a supplement, end of problem. If it's Part D, and it is on the formulary for most plans, as a specialty drug, I am not sure if the D for out of professional setting/B if administered in a medical setting applies absolutely. It will be injected at a medical facility. Once a month Abilify.

 

[Todd King]

It should still apply. If it is administered in the Dr's office it should be under Part B.

I'm sure there are exceptions to this rule though.

 

[kgmom219]

You need to be very, very careful on this one. The client has severe mental health issues already. Insurance issues aren't going to help and you don't want to be the bad guy.

1. Typically, Abilify moves from injectable to oral at some point (as soon as possible)
2. So if it starts as covered under Part B (which the doc was probably doing to help with the cost), Medicare is probably only going to allow it for X months under Part B
3. When it goes to Part D, they are going to need the cost associated with it (since right now its free).

My advice: they need to talk to the doc and ask how long they can keep doing the injections under Medicare Part B. That way, if/when it is no longer covered under B and they have to come up with some money, its not your fault. Although, if they take the generic, its not expensive. It usually what they are taking on top of the Abilify that causes the problems.

 

[somarco]

Always good to have someone around who knows her way around drugs.

 

[Todd King]

You need to be very, very careful on this one. The client has severe mental health issues already. Insurance issues aren't going to help and you don't want to be the bad guy.

1. Typically, Abilify moves from injectable to oral at some point (as soon as possible)
2. So if it starts as covered under Part B (which the doc was probably doing to help with the cost), Medicare is probably only going to allow it for X months under Part B
3. When it goes to Part D, they are going to need the cost associated with it (since right now its free).

My advice: they need to talk to the doc and ask how long they can keep doing the injections under Medicare Part B. That way, if/when it is no longer covered under B and they have to come up with some money, its not your fault. Although, if they take the generic, its not expensive. It usually what they are taking on top of the Abilify that causes the problems.

I figured there would be an exception and someone would lay it out.....good on ya!

 

[WCMason]

Client meeting soon, and manufacturer offers to pay 100% while no insurance in place, this insured was referred to me after glitch, not enrolled in Medicare for 12/1/17 when T65, then kicked out of ACA coverage back to 1/1/18. They called me on 2/1/18 instead of 1/31, so no insurance or Medicare until 3/1.
When there is insurance, the manufacturer says they will help for Rx not covered on Part D. If the injectible is covered by Part B and they purchase a supplement, end of problem. If it's Part D, and it is on the formulary for most plans, as a specialty drug, I am not sure if the D for out of professional setting/B if administered in a medical setting applies absolutely. It will be injected at a medical facility. Once a month Abilify.

If this person turned 65 in December and applied for Medicare in February the Part B effective date will be May 1, not March 1.

 

[somarco]

f you sign up for Part A (if you have to buy it) and/or Part B in this month: Your coverage starts:
The month you turn 65 1 month after you sign up
1 month after you turn 65 2 months after you sign up
2 months after you turn 65 3 months after you sign up
3 months after you turn 65 3 months after you sign up

When will my coverage start? | Medicare.gov