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Medicare Part D and anti-retrovirals

Discussion in 'XMRV Testing, Treatment and Transmission' started by Sushi, Dec 2, 2009.

  1. Sushi

    Sushi Moderator and Senior Member Albuquerque

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    For those of you on a Medicare drug plan, we have until December 31st to change plans. I have been looking at the formulary of my current plan to see what anti-retrovirals it covers. It does cover AZT as a tier 1 drug (cheap) and the generic form of Raltegravir (tier 2--mid-level co-pay)--this is Blue Cross's plan.

    Has anyone else looked at this and if so what do other plans cover? At this point it is kinda throwing the dice as we don't know what will prove effective (and I am trying natural anti-retrovirals in the meantime) but possibly there will be some news by the December 31st deadline.

    Any thoughts?
    Sushi
  2. calzy

    calzy Senior Member

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    :eek:trying to decide on which plan to choose put me in bed for a day.....mental exhaustion! This is an important decision, those left with a brain, PLEASE post what you find.

    Hugs
  3. I am not very bright but it seems to me that choosing an insurance plan to cover 'drug unknown' for 'results and response plan also yet unknown' is just luck of the draw at this point. Maybe I am just a pessimist. I WANT to believe, only I don't know what to believe IN just yet.

    Please forgive me.
  4. Sushi

    Sushi Moderator and Senior Member Albuquerque

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    I'm just hoping that there might be some news by the Dec 31st deadline so that we can make a more informed decision. Otherwise, the "unknown drug" could cost a great deal out-of-pocket.

    Sushi
  5. Hysterical Woman

    Hysterical Woman Senior Member

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    Medicare Part D

    Hi All,

    Sushi, thanks for starting this thread, I have been thinking a lot about it myself. I am extremely unhappy with my current provider which has paid almost nothing toward my current prescription (only taking one inexpensive one), but wants to almost double my premiums for 2010.

    At this point, I can't begin to guess what medications might be recommended to us in the coming year. For me personally, I have seen Dr. Lerner twice and he recommends a combo of valtrex and valcyte for a year. I could probably swing the valtrex costs, but even with my part D insurance the valcyte would still be around $7500 for the year which would not include all the blood work needed to make sure it is not damaging my liver. That's out of my league.

    So, my game plan at this point is trying to find out if anyone out there is actually happy with their Part D plan regardless of the specific drugs it might cover?

    Thanks for any information,

    Maxine
  6. Sushi

    Sushi Moderator and Senior Member Albuquerque

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    Hi Maxine,

    I have been happy with Blue Cross's option 3 plan, though they are increasing my monthly premium from $32 to $44 next year and changing co-pays. I used to get generics free--now I'll pay $4. For next year their tier 2 meds on this plan will be $30, and their tier 3, $70. There is an annual deductible of $300 for brand name drugs. They also have options 1 & 2, but I haven't yet investigated them. It also goes state by state.

    I have been looking at their formulary to see what they cover in the anti-viral/retroviral range. I don't know a lot of the drugs but Valtrex is covered as a tier 3, and Valcyte as a "covered specialty drug." For covered specialty drugs you pay 25% of the cost--of course till you reach the donut hole. Do you know the price pharmacies charge for Valcyte without insurance? On this plan, if I understand it correctly, it would be 25% of that.

    Hope this helps. I am going to investigate other plans too.

    Sushi
  7. SeaShel

    SeaShel Senior Member

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    I don't know about the rest of you, but I've had to change plans each and every year because of the plan changing what it covers and/or the premium. And I'm down to just a few meds - not a long list at all.

    A few weeks ago I was looking for one that would cover Savella, and someone else here on the board (sorry, don't remember who or on what thread) said they had found only ONE that was going to cover it. Moot point now, one side effect I developed was pins and needles down the left arm, even on a low dose.

    To echo what's all ready been said, I've decided to just go ahead and go with whatever plan will cover my 2 main meds (pain and muscle relaxer) for this next year. The current plan (Aetna) raised their price by about $10/mo and are dropping my muscle relaxant.

    As impatient as I am, I feel like it's still likely to be 6 or more months before we start seeing possible answers/meds. Waiting another 6 months past that to pick a new plan that will cover whatever has "emerged" as a drug therapy won't be that unreasonable. Especially as I have developed such a sensitivity to meds that the dr. will be giving me samples (I hope!) first to see how it goes, it may not be much of a wait to change plans appropriately.

    Also, for those of you who may not have experienced this, please remember that it is ridiculously easy to hit the donut hole. They use the actual price of the drug, not just what they pay towards it. To use Sushi's example of Valcyte, let's say it costs $1000 per month (just to use round numbers with my pea brain). She would pay $250, but the entire $1000 is applied to the number that gets you to the donut hole. So before March is over, she's in donut hole hell and paying 100% of everything till she hits the out of pocket max. Ouch ouch ouch.

    Shelley
  8. gracenote

    gracenote All shall be well . . .

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    my two bits

    Hi Maxine,

    I hesitate to join in here because these types of things don't behave properly in my brain. But I'll try to offer just a little bit . . .

    I was on Valcyte for 7 months. At two 450 mg tablets per day, the cost was $2,187 which my plan covered completely. I have Wellcare. It has been great for covering all the drugs (except for compounds) that I need. I also have MediCal which may at times be making up the difference, but on the few statements I pulled, WellCare has done it all.

    As far as the necessary blood tests, I don't know if Medicare or MediCal paid, but I didn't.
  9. Dr. Yes

    Dr. Yes Shame on You

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    Hi everyone :D

    First-time poster here. I'm so glad I joined this group! I'm having to decide about Medicare Part D for the first time this year; I am covered by my mother's employer insurance (Aetna) via a nifty loophole (involving getting sick while still a dependent, 17 years ago), plus I have Medicare and Medicaid... So far Aetna has paid for all of my 'standard meds' (though not things like Kutapressin, of course), but now I'm getting letters saying I will be automatically enrolled in a Part D plan unless I choose one first.

    Question is, if I sign up for a Part D plan which sounds like it would have worse coverage than Aetna, wouldn't Aetna stop paying for my prescriptions? I can't afford ANY out-of-pocket expenses; all my SSD is being deducted to pay for the nursing home I'm currently forced to stay in, and later will be used to pay for a home health aide (I'm practically bedridden). Does anyone know if you are REQUIRED to enroll in a Part D even if you already have private insurance coverage?

    Thanks for the info you guys have already posted here... btw, gracenote, is Wellcare a Part D plan?
  10. gracenote

    gracenote All shall be well . . .

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    Part D

    I'm so not trusting my brain at this moment that I actually googled Wellcare to check. Yes, it is a Part D plan.

    I am not recommending it over the other plans. It was what was assigned to me and by default became mine. Because it's worked well for me I have not switched. I have many ill friends and no one else is using this particular plan. Actually, they are all using different plans from each other, so no consensus on what is best that I know of. I am told that there are kind people who will spend time on the phone with you helping you figure it all out. At the moment I don't know the name of the organization or the number but could find out if needed.
  11. Dr. Yes

    Dr. Yes Shame on You

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    Thank you!!
    I definitely could use one of those "kind people" on this issue; the medical insurance thing is too much for my brain too. If, and ONLY if, you have the mental/physical energy to do so at any point, I would be really grateful if you could find a number like that (if one exists)....Absolutely no problem if you can't; I'm trying to have family figure it out anyway. (picture winking smiley face here)
  12. Robin

    Robin Guest

    Can you change the part D plan mid year or are we stuck with it?
  13. calzy

    calzy Senior Member

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    Robin

    You are stuck with it.
  14. gracenote

    gracenote All shall be well . . .

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    How to Compare Plans Properly

    Maybe this will help you Dr. Yes. This came from AARP today. You have three choices. The bottom one is the one I was referring to.


    HOW TO COMPARE PLANS PROPERLY

    Use Medicare's online Drug Plan Finder.
    www.medicare.gov

    Call the Medicare help line and ask for a similar search.
    1-800-633-4227

    Call your State Health Insurance Assistance Program (SHIP). To find the number for your state, go to www.shiptalk.org or call 1-800-677-1116.
    It is the people at SHIP that I've been told are "kind people" and very helpful. (I haven't talked with them myself.) Hope this helps.
  15. Dr. Yes

    Dr. Yes Shame on You

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    Thanks so much! The SHIP sounds like just what I'm looking for... I'll look em up as soon as I can.

    Thank you again, I really appreciate your help! :):)
  16. klutzo

    klutzo Senior Member

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    Wellcare

    I have used Wellcare for my Medicare Part D provider ever since the program started. It pays for 6 of the 8 drugs I take, and pays partially for the 7th one.

    It has never paid for the muscle relaxer, and I do not know of ANY plans that pay for muscle relaxers or narcotics, including my husband's most expensive of all Blue Cross Plan. There is some definite puritanical prejudice against mental health or pain drugs. Most muscle relaxers are mental health drugs so are not covered. It depends on the drug though. Anti-spasmodics are usually covered.

    Wellcare's 2010 Formulary says it does not cover any anti-retrovirals, nor does it cover Valcyte or Valtrex. I have found in the past that the formulary is not always correct. For example, they covered my Armour Thyroid, even though it was not listed. Now I am switching to Levothyroxine since Armour is gone. I don't have the T3 conversion problem, and decided to leave the small supply of Westhroid and NatureThroid for those that do.

    I will probably stick with Wellcare this year out of laziness. Last year I spent a whole day comparing plans, and it turned out they all covered the same things for me, but most other plans cost a whole lot more. I admit I did not look for antiretrovirals last year, since the XMRV issue was not known then.

    I'm pessimistic and don't expect these things to be covered for us within the coming year. I think this will be dragged out as long as possible by Insurance companies looking for excuses not to cover us.

    klutzo
  17. gracenote

    gracenote All shall be well . . .

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    my Valcyte was approved

    I think my doctor had to write to Wellcare and tell them I needed Valcyte, and because my CMV levels were so high, they approved it. My guess (and it's just a guess) is that some drugs will be covered if the case if made for their necessity. I don't know how you figure that out ahead of time, though.
  18. calzy

    calzy Senior Member

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    Walgreens

    Walgreen can print out the best 5 plans based on the drugs you now take. This is very helpful for the current meds you are taking, but it seems we are at any drug companys mercy for future meds for:confused: xmrv.
  19. SeaShel

    SeaShel Senior Member

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    Klutzo

    Hi Klutzo -

    My Part D plans have always paid for my narcotics and muscle relaxer, but it may be considered an anti-spasmodic. The muscle relaxer is also the reason I've had to change every year, it's the one that seems to be dropped off of the formularies (and it's not even expensive, go figure).

    It only pays about 50% of the narcotic however. The pharma company has been providing coupons for the last few years, so I've been able to get it for about $20-30 per month.

    This years Part D was Aetna, would have to look up who has gone before.
  20. sleepwalking

    sleepwalking

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    Medicare Part D

    "I do not know of ANY plans that pay for muscle relaxers or narcotics, including my husband's most expensive of all Blue Cross Plan. There is some definite puritanical prejudice against mental health or pain drugs. Most muscle relaxers are mental health drugs so are not covered. It depends on the drug though. "

    I use First Health for my medicare part D and they do cover all my meds including Pain, valtrex, etc.

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