UNITED STATES—Toni: I will turn 65 in May and am currently covered by my wife’s employer group health insurance. Currently, I am fighting stage 3 cancer of the kidney and the prognosis is good because I am participating in a clinical trial for a new cancer medication which costs over $18,000 per month. With this clinical trial, I am paying $0 for a medication which is curing my cancer.
I am not planning to enroll in Medicare until my wife retires next year, when she turns 65. I am concerned about Medicare’s famous donut hole and if this new prescription called Sutent is covered by Medicare’s Part D prescription drug plan. How long will it take me to get into the donut hole or will I even get in it? Please explain Medicare and clinical trials and what I should do? Thanks, Matthew
Matthew: You are very smart to remain on your wife’s employer benefits because you both can enroll in Medicare Parts A and B when your wife retires next year. At that time, you will be eligible for a SEP (Special Enrollment Period) avoiding the Medicare Part B penalty and be able to enroll in a Medicare Part D prescription drug plan.
Since you are enrolling in Medicare Part B for the first time, you qualify for the Medigap/Medicare Supplement 6-month enrollment period to begin the month your Medicare Part B begins without having to answer health questions.
Original Medicare and your Medicare Supplement will work together with your clinical trial program to cover your medical needs. Original Medicare covers the routine costs of qualifying clinical trials. Your Medicare Supplement plans will pay the out of pocket that Original Medicare does not pay that meets Medicare qualifications.
When one chooses a Medicare Advantage plan with a clinical trial for a serious health issue, the Medicare Advantage plans is required to reimburse beneficiaries for the difference in out-of-pocket cost sharing between Fee for Service and their Medicare Advantage plan.
Original Medicare with a Medicare Supplement does not have a network and one’s medical provider must bill Medicare. With a Medicare Advantage plan, one may have a network with referrals from an HMO or maximum out of pocket with a Medicare Advantage PPO.
Let’s discuss your $18,000 clinical trial prescriptions and if you will go in the “famous Donut Hole.” Prescriptions are the most important option discussed when a Toni Says® Medicare consultation is performed.
Yes, Matt…you go in the “Donut Hole” the very second you order the prescription Sutent and for that reason, we search the Medicare site for which Medicare Part D plan best meets your Medicare and financial needs. Always enroll in the Medicare Part D plan which covers all your prescriptions even though the most expensive prescription is covered by the clinical trial programs and costs you $0. There may be a time when that expensive prescription is no longer covered by the clinical trial and you have the “Donut Hole” experience.
Your Medicare Part D prescription drug monthly costs for the $18K monthly cancer medication Sutent is $2471, 1st month with you going in and out of the Donut Hole and into Catastrophic coverage with $938.57 monthly, the 2nd month to the end of the year. If one is not enrolled in a Part D plan that covers the $18K monthly prescription, then you would pay 100 percent out of your pocket.
Medicare planning is vital especially when one has a serious health condition as you have Matt. Take your time and search what best option meets your needs.
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If you are still confused and would like to discuss your specific Medicare circumstances either email firstname.lastname@example.org and the Toni Says® team can help you.