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Topic: Worried about Herceptin on Medicare

Forum: Employment, Insurance, and Other Financial Issues —

Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Aug 12, 2020 08:57PM

illimae wrote:

Hi all, I’m due to be switched to Medicare in December by SSDI and my retirement plan (Employees retirement system of Texas) will then change me from BCBS to either Healthselect Medicare Advantage by Humana, which is out of network for MD Anderson (MDA) or healthselect secondary BCBS, which I’m told is not accepted at all by MDA.

Those of you on Medicare and receiving Herceptin every 3 weeks, is it covered? I’m concerned I’ll have to pay the remaining 20%, which would be several thousand dollars for each infusion.

I appreciate any Medicare/insurance tips.

Diagnosed at 41 Stage IV De Novo Dx 11/16/2016, IDC, Left, 5cm, Stage IV, metastasized to bone, Grade 3, 3/13 nodes, ER+/PR-, HER2+ (IHC) Targeted Therapy 1/1/2017 Perjeta (pertuzumab) Chemotherapy 1/2/2017 Abraxane (albumin-bound or nab-paclitaxel) Targeted Therapy 1/2/2017 Herceptin (trastuzumab) Surgery 6/26/2017 Lumpectomy: Left; Lymph node removal: Underarm/Axillary Radiation Therapy 8/10/2017 Breast, Lymph nodes Dx 10/5/2017, IDC, Left, 5cm, Stage IV, metastasized to brain, Grade 3, 3/13 nodes, ER+, HER2+ (IHC) Radiation Therapy 10/19/2017 External: Brain Radiation Therapy 4/18/2018 External: Brain Radiation Therapy 5/23/2019 External: Brain Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Aug 12, 2020 11:10PM MinusTwo wrote:

Mae - I am on standard Medicare Part B (not the Advantage plan Part C) and I can choose any docs or hospitals that I want. I have a medigap plan through AARP (United Health Care) that pays the balance - 20% that medicare does not pay. I chose this because I wanted to see who I wanted to see, when I wanted to see them, with no gate keepers.

That said, there are still lots of options if you go with standard Part B Medicare and a Medigap policy. For example - I pay no co-pay but I do pay my own deductible every year (around $190 per year). I have a friend who has a $10.00 co-pay at every appointment but pays no deductible. I'd guess there are at least 10 different choices. That said - I NEVER have had to pay a dime over my deductible for doctors, chemo, infusions, treatment, surgeries, scans, PET/CT, MRI, etc. I think that $1000 was the hospital deductible for Part A for the surgeries - but that may now have a time limit shorter than a year. I mean seriously - Herceptin for a year, Perjeta, second round of chemo with recurrence, podiatrist for lost toenails from chemo, neurologist for neuropathy. The only thing that is not covered is an MMR vaccine, which they didn't have when I was a kid & a few things like that. And dental & glasses are not covered.

Sounds like you're only considering an Advantage plan. I have friends who love the prices, but you are right - there are hospitals & docs that are always out of network. I didn't think there was a 20% deductible with an Advantage plan, but I could be wrong. If you have a nurse navigator at MDA, I'd ask about the two plans you are considering. Otherwise maybe call their business office. Usually people there really care. Or maybe the office manager for your doc(s). Be sure the docs you love will accept whatever plan you choose. One of the reasons for my choice was to have full access to MD Anderson when & if I need it.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
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Aug 13, 2020 01:55AM Olma61 wrote:

In some states there aren’t any Medigap plans for people under 65 on SSDI so you might be forced to chose an Advantage plan.

You can check here to see what’s available for your situation


https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m

It sounds like your retirement plan pays for the two you mentioned, but maybe there are other Advantage OR Medigap plans you can pay for yourself, that include MDA in their network, listed on the site.

Also have you spoken to a financial counselor or social worker at the hospital yet? They usually know all about how to get your infusions covered

10/30/2017 Xgeva for bone mets 5/31/2018 Taxol finished! "If one just keeps on walking, everything will be all right” - Kierkegaard Dx 8/3/2017, IDC, Right, 2cm, Stage IV, metastasized to bone, Grade 2, ER+/PR+, HER2+ (IHC) Targeted Therapy 10/28/2017 Perjeta (pertuzumab) Targeted Therapy 10/28/2017 Herceptin (trastuzumab) Chemotherapy 10/29/2017 Taxol (paclitaxel) Hormonal Therapy 5/14/2018 Arimidex (anastrozole) Radiation Therapy 5/29/2019 External: Bone
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Aug 13, 2020 10:34AM Spookiesmom wrote:

I have an Advantage plan from Humana and have been very pleased with it. Switched from regular Humana plan to this 8 years ago. $10 copay to specialist, $3.60 generic med. $0.00 for Ibrance. That’s 13 k a month. My MO office arranged financial aid for that. No deductible, no cap on spending Last year, with surgery and rads again, I hit catastrophe and didn’t have dr copays the rest of year

Your time frame is during open enrollment so I suggest starting now to talk to different insurance co about plans available in your area your hospital or MO office should be able to help too.

I still pay the monthly Medicare amount, 135? But that’s all. This isn’t a supplement where YOU pay a monthly premium in addition to everything else,

Reoccurrence 3-19. Dx IDC, Stage IIIA, Grade 3
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Aug 13, 2020 10:56AM illimae wrote:

Thank you everyone. MDA does take Medicare, so my big concern is the IV Herceptin and Perjeta, which falls in the part B category covered at 80%. The pre-insurance price tag is about $46,000 per treatment (every 3 weeks) 20% is $9,600. Still gathering info but not finding any clear answers yet.

Diagnosed at 41 Stage IV De Novo Dx 11/16/2016, IDC, Left, 5cm, Stage IV, metastasized to bone, Grade 3, 3/13 nodes, ER+/PR-, HER2+ (IHC) Targeted Therapy 1/1/2017 Perjeta (pertuzumab) Chemotherapy 1/2/2017 Abraxane (albumin-bound or nab-paclitaxel) Targeted Therapy 1/2/2017 Herceptin (trastuzumab) Surgery 6/26/2017 Lumpectomy: Left; Lymph node removal: Underarm/Axillary Radiation Therapy 8/10/2017 Breast, Lymph nodes Dx 10/5/2017, IDC, Left, 5cm, Stage IV, metastasized to brain, Grade 3, 3/13 nodes, ER+, HER2+ (IHC) Radiation Therapy 10/19/2017 External: Brain Radiation Therapy 4/18/2018 External: Brain Radiation Therapy 5/23/2019 External: Brain Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)

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