Crazy Expensive Tier 5 Drug

[beachbum2012]

I'm working with a husband and wife who are coming off employer coverage as the husband is retiring and they'll both be 65 in December. The wife has a condition called polymyositis and is confined to a wheelchair. She's been on Medicare A&B for several years since she didn't know she didn't need Part B being covered thru her husband's employer.

Anyway, twice a month a health aide comes to her house and administers a drug called Gammagard 500mL at a time. She maxes out her max out of pocket for their employer coverage because of this drug. However, once she gets her own Medicare supplemental insurance, I'm not sure if this drug will be a Part B or Part D expense. I did find it in the plan finder on Medicare's website, and based on the amount she needs monthly the retail cost of it is over $11,000 each month. Her copays would total almost $10k for the year since most of the year she'd be in catastrophic coverage.

Does anyone have experience with meds like this? Any chance it could be covered under Part B if she goes to have it administered in the doctor's office instead of at home? There is a pharmaceutical assistance program with this drug, and their income is pretty low as their only income will be Social Security for each. Is there a good chance she could qualify? I can't imagine how a couple living just on SS income is expected to afford this much for a drug copay.

 

[yogooglethis]

I'm working with a husband and wife who are coming off employer coverage as the husband is retiring and they'll both be 65 in December. The wife has a condition called polymyositis and is confined to a wheelchair. She's been on Medicare A&B for several years since she didn't know she didn't need Part B being covered thru her husband's employer.

Anyway, twice a month a health aide comes to her house and administers a drug called Gammagard 500mL at a time. She maxes out her max out of pocket for their employer coverage because of this drug. However, once she gets her own Medicare supplemental insurance, I'm not sure if this drug will be a Part B or Part D expense. I did find it in the plan finder on Medicare's website, and based on the amount she needs monthly the retail cost of it is over $11,000 each month. Her copays would total almost $10k for the year since most of the year she'd be in catastrophic coverage.

Does anyone have experience with meds like this? Any chance it could be covered under Part B if she goes to have it administered in the doctor's office instead of at home? There is a pharmaceutical assistance program with this drug, and their income is pretty low as their only income will be Social Security for each. Is there a good chance she could qualify? I can't imagine how a couple living just on SS income is expected to afford this much for a drug copay.

Looks this particular drug could be either but for it to be covered under B it has to be for treatment of an immune deficiency disease.Looks like what she has possibly could be in that realm.I would ask your client to ask the doctor who prescribes it to lay out likely scenario with their experience with other medicare patients prescribed the drug who usually pays for it B or D - they should know. ..Sometimes whether a drug is covered under part b or depends on how the drug is administered and whether the medical provider ordered it directly or if it was " brown bagged " from the pharmacy to provider under part D


Cover under Part B if the patient has a diagnosis of primary immune deficiency disease and the
medication is being administered in the doctor’s office or ambulatory infusion setting.

 

[Stephen]

Looks this particular drug could be either but for it to be covered under B it has to be for treatment of an immune deficiency disease.Looks like what she has possibly could be in that realm.I would ask your client to ask the doctor who prescribes it to lay out likely scenario with their experience with other medicare patients prescribed the drug who usually pays for it B or D - they should know. ..Sometimes whether a drug is covered under part b or depends on how the drug is administered and whether the medical provider ordered it directly or if it was " brown bagged " from the pharmacy to provider under part D


Cover under Part B if the patient has a diagnosis of primary immune deficiency disease and the
medication is being administered in the doctor’s office or ambulatory infusion setting.

Pretty much what he said. Gammaguard needs to be delivered with an infusion pump to be covered by part b.

A portion of the $10k that Baxter Pharm charges for this drug pays caseworkers that do this every day to keep the Gammaguard flowing, I would call them.

 

[Guest]

I would also make sure that the nurse is covered under her supplement.
I have a customer with a plan F, she had blood poisoning and needed iv meds at home for over 2 weeks, none of this was covered by her supplement because Medicare does not cover at home iv administration or the meds.

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Note for Medicare patients needing infusion therapy. | IDA

 

[policy doctor]

Didn't know about the home infusion meds not covered by medicare.
So many twists to healthcare that unless you have a case presented to you, we truly do not know.

Guess I assumed home health care but that is restricted to hospital discharge cases only??

Tkx for link, insgal.

 

[beachbum2012]

Looks this particular drug could be either but for it to be covered under B it has to be for treatment of an immune deficiency disease.Looks like what she has possibly could be in that realm.I would ask your client to ask the doctor who prescribes it to lay out likely scenario with their experience with other medicare patients prescribed the drug who usually pays for it B or D - they should know. ..Sometimes whether a drug is covered under part b or depends on how the drug is administered and whether the medical provider ordered it directly or if it was " brown bagged " from the pharmacy to provider under part D


Cover under Part B if the patient has a diagnosis of primary immune deficiency disease and the
medication is being administered in the doctor’s office or ambulatory infusion setting.

I don't think her diagnosis is considered an auto-immune disease. Her treatment is considered "IVIG" currently. It looks like Medicare doesn't cover home infusion at all, so they've resolved they'll need to go to a facility to get the drug administered. She called a local hospital's outpatient facility, and they said they could do it. But based on her diagnosis, they didn't know if Medicare would approve it or not.

I spoke with a very helpful girl at an infusion pharmacy about this situation. She said whether Medicare Part B covers it or not is not only based on the drug and the facility, but on the specific diagnosis of the patient. Also, she said some MAPDs are like employer group plans and will cover the treatment under an "exact fill policy" even if Medicare doesn't approve it under Part B. But, most likely the MAPD would charge a 20% copay and this lady would still be looking at hitting her MOOP every year.

Nobody seems to be able to give me (or her) a straight answer. I tried calling Medicare, have made several calls to the infusion pharmacy, outpatient infusion centers, etc. And, she can't get a straight answer from her neurologist or the staff there, and every time she brings up the topic to him, he changes the subject.

Has anyone had any luck getting a definite answer on a case like this in the past? I should put her in a medsupp if the treatment falls under Medicare Part B, but a MAPD if it doesn't and the certain MAPD at least covers it. Any help is appreciated.

 

[unic.consulting]

I don't think her diagnosis is considered an auto-immune disease. Her treatment is considered "IVIG" currently. It looks like Medicare doesn't cover home infusion at all, so they've resolved they'll need to go to a facility to get the drug administered. She called a local hospital's outpatient facility, and they said they could do it. But based on her diagnosis, they didn't know if Medicare would approve it or not.

I spoke with a very helpful girl at an infusion pharmacy about this situation. She said whether Medicare Part B covers it or not is not only based on the drug and the facility, but on the specific diagnosis of the patient. Also, she said some MAPDs are like employer group plans and will cover the treatment under an "exact fill policy" even if Medicare doesn't approve it under Part B. But, most likely the MAPD would charge a 20% copay and this lady would still be looking at hitting her MOOP every year.

Nobody seems to be able to give me (or her) a straight answer. I tried calling Medicare, have made several calls to the infusion pharmacy, outpatient infusion centers, etc. And, she can't get a straight answer from her neurologist or the staff there, and every time she brings up the topic to him, he changes the subject.

Has anyone had any luck getting a definite answer on a case like this in the past? I should put her in a medsupp if the treatment falls under Medicare Part B, but a MAPD if it doesn't and the certain MAPD at least covers it. Any help is appreciated.

You mentioned that they are both only on SS earlier. Has she applied for LIS?

 

[beachbum2012]

You mentioned that they are both only on SS earlier. Has she applied for LIS?

She wouldn't qualify. They've got a $100k IRA.

 

[kgmom219]

1. Stephen is right. Call Baxter
2. Unless you have the diagnosis, it won't matter who you call.

The FDA has approved it for primary immunodeficiency (PI) and multifocal motor neuropathy (MMN).

It is being used off label for alzheimers. THAT'S why the neurologist is changing the subject. She's dealing with alzheimers onset and he is either prescribing it for that or hasn't told her. (I'm pretty cyncial)

That's why you keep getting the runaround. You cannot determine if its going to be covered unless you get the diagnosis code. Much less figure out if its Part B or D.

GAMMAGARD® (Immune Globulin Infusion) has some reimbursement cards.

Good luck. You're a good agent for jumping through all these hoops to help this woman!

 

[beachbum2012]

1. Stephen is right. Call Baxter
2. Unless you have the diagnosis, it won't matter who you call.

The FDA has approved it for primary immunodeficiency (PI) and multifocal motor neuropathy (MMN).

It is being used off label for alzheimers. THAT'S why the neurologist is changing the subject. She's dealing with alzheimers onset and he is either prescribing it for that or hasn't told her. (I'm pretty cyncial)

That's why you keep getting the runaround. You cannot determine if its going to be covered unless you get the diagnosis code. Much less figure out if its Part B or D.

GAMMAGARD® (Immune Globulin Infusion) has some reimbursement cards.

Good luck. You're a good agent for jumping through all these hoops to help this woman!

The diagnosis is polymyositis. She's in a wheelchair. Her muscles are breaking down, it doesn't have anything to do with a cognitive disorder. She was diagnosed ~20 years ago. In her words, the doctor said "it's not quite lupus, and not quite MS, although it could get there".

Every place/person I've talked to doesn't know how Medicare covers it even after telling them the diagnosis. I don't know what the diagnosis code is, or if it differs from facility to facility. It just seems like this drug isn't usually used for her diagnosis, so no one is able to give me a straight answer until the insurance (Medicare or a MAPD) would actually get billed.