UNITED STATES—Toni: I will turn 65 in September 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. 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?
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 will be enrolling in Medicare Part B for the first time when she retires, you qualify for the Medigap/Medicare Supplement 6-month open 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 prescription drug 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” when you enroll in a Medicare Part D plan when you are no longer on your wife’s employer group health insurance. Medicare Part D is an 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 will 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 must use the Medicare Part D plan.
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 Catastrophic coverage with $938.57 monthly, the 2nd month to the end of the year. Not enrolled in Part D plan not covering the $18K monthly prescription, then you pay 100 percent out of pocket.
Medicare planning is vital especially when one has a serious health condition. Take your time and research what option meets your needs.
Toni King, author of the Medicare Survival Guide® is giving a $5 discount on the Medicare Survival Guide® Advanced book and bundle packages for the Toni Says® newspaper article readers at www.tonisays.com.