Part B Medicare Nebulized Drugs
- Thread starter scanboyd
- Start date
Most drugs are going to be covered under part D. I advise you get part D, or you won't be able to get the meds you need. If you give me specifics, like whether you'll be getting a Part D plan or a Part C plan and if so which one? I can help you out a bit, I work at a call center for a part D company for a living =]
Hello Lena Bean. I have medical ins. through my previous employer of 35 yrs. that is self funded, which pays good toward drugs. Just wondering about part B drug coverage. I see that in part B, drugs used with a nebulizer are covered under CF. Just wondering if anyone uses this and what drugs they are getting through Part B Medicare. Some of these nebulized medicatons are so darn exp. would like to take some of the burden of my Ins. if possible. Thank you for your help Leana Bean!
*Xopenex 1.25 mg. TID *7cc 3%NaCL Nebulized TID *Pulmozyme 1MG/ML, 2.5 mg daily *Acetylcysteine 20%, 1cc nebulized TID * Symbicort 160-4.5 MCG/ACT 2 puff BID *Tobi 300 MG/5 ML Nebulized BID for 28 days *Cayston,Aztreonam 75mg TID Neb 28days on 28days off *Colistin Sulfate Powd 150mg Neb BID Alternat with Tobi 28 days on
*Xopenex 1.25 mg. TID *7cc 3%NaCL Nebulized TID *Pulmozyme 1MG/ML, 2.5 mg daily *Acetylcysteine 20%, 1cc nebulized TID * Symbicort 160-4.5 MCG/ACT 2 puff BID *Tobi 300 MG/5 ML Nebulized BID for 28 days *Cayston,Aztreonam 75mg TID Neb 28days on 28days off *Colistin Sulfate Powd 150mg Neb BID Alternat with Tobi 28 days on
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RytheStunner
Guest
Part B tends to cover the more expensive drugs like Pulmozyme, Cayston, and TOBI. Those are not covered under Part D (from my experience, at least).
Hi Scanboyd,
Medicare part B covers just a select few. Pulmozyme and Tobi are the only 2 that I know of for certain. I *think* they may cover acetylcysteine but I have such a low copay after my primary pays that I haven't bothered with seeing if Walgreens can bill part B for it. I get my others from CF Services pharmacy where they bill my primary and then my part B. Not sure if retail pharmacies can bill part B? Maybe you can let me know if you are able to get the acetylcysteine covered under part B?
Ry- has part B covered Cayston for you? As far as I know they have not added it yet and are not covering it but hopefully will eventually. If they are covering it then I am missing the boat!
Scan, good luck and let us know if you have other questions!
Autumn
Medicare part B covers just a select few. Pulmozyme and Tobi are the only 2 that I know of for certain. I *think* they may cover acetylcysteine but I have such a low copay after my primary pays that I haven't bothered with seeing if Walgreens can bill part B for it. I get my others from CF Services pharmacy where they bill my primary and then my part B. Not sure if retail pharmacies can bill part B? Maybe you can let me know if you are able to get the acetylcysteine covered under part B?
Ry- has part B covered Cayston for you? As far as I know they have not added it yet and are not covering it but hopefully will eventually. If they are covering it then I am missing the boat!
Scan, good luck and let us know if you have other questions!
Autumn
Hello RytheStunner, has Medicare Part B covered Cayston for you? I am trying to lighten the load of my personal Ins. since we are self funded. How does it work for you. Do they bill your ins. company first or Medicare? Which is billed second, does the pharmacy bill your drug portion of your ins. for the balance of the bill. How much co pay do you have to pay in general. Thanks for the info.
Hello tripless15, I have not tried to use Part B for drugs, but am considering it. Did not want to try it if not worth it. Question to you Autum, I thought they would bill Medicare first then your secondary ins.. Do they bill the drug portion of your insurance or like you were in the hospital portion. How much copay do you have to pay if you do not mind telling me after Medicare and your primary ins. pays. Since my personal ins. is a self funded policy I am trying to lighten the load for them. If it helps with Tobi and Pulmozyme that would be good. I just do not want to up set the apple cart and have me to pay any more than I am already paying as far as co pay.
According to the post by RytheStunner they cover Cayston.
Does anyone get Cayston through Medicare Part B.
Thanks to all for the info. hope it will help others!!
According to the post by RytheStunner they cover Cayston.
Does anyone get Cayston through Medicare Part B.
Thanks to all for the info. hope it will help others!!
I am strictly Medicare part A and B, D as far as coverage goes with a medigap insurance... From what I understand, what is covered under part B is are albuterol, duonebs, pulmozyme, TOBI, and NAC (Mucomyst) and a few others, but not Cayston (as far as I know). Part B pays for 80% of the costs, the rest is your financial obligation. This is where my medigap insurance kicks in, my policy picks up the remaining 20%, so I pay nothing, no co pays. I would be flat broke if I were on TOBI and had to pay 20% out of my pocket! Yes, it costs extra money per month for a medigap policy, but it has saved me thousands when it comes to admissions, part B meds, doctor's visits etc. You just need to figure out what will work best for you, sometimes you need to be a little creative to get around some of Medicare's pitfalls (such as home IV's, they don't cover supplies, but if you have part D insurance, you could get some meds ordered ahead of time to keep on hand for when it is needed, which is exactly what I do with my doc's blessing)
If you have any more questions, shout it out and we'll see what we can come up with!
Jenn 40 wCF
If you have any more questions, shout it out and we'll see what we can come up with!
Jenn 40 wCF
beautifulsoul
Super Moderator
This is an interesting topic. I just wanted to chime in and add that it seems like it's strongly based on what your primary insurance is? I'm covered with part D like Lena Bean but since I'm post transplant I do not use any kind of nebulizer drugs. All of my oral meds (15+) are covered most of the time under part D I believe. I'm not very knowledge able about this subject. It's a confusing task for everyone.
Amber, if you had a transplant while you had Medicare (did Medicare pay for it, either as a primary or secondary?), your anti rejection meds should be covered under part B. I agree, confusing, still learning something new all of the time regarding Medicare and I have been on it for nearly 8 years now lol
Jenn 40 wCF
Jenn 40 wCF
Hello again! I am on my husband's United Healthcare policy through his employer as my primary. So Medicare is currently my secondary. So my prescriptions are billed through United Healthcare first, then to Medicare Part B. The United Healthcare plan pays 90% of prescription cost. So here's how it works with Pulmozyme for example: Pharmacy cost of Pulmozyme $2,228, United Healthcare pays 90% and would leave me with a $228 copay. Instead it is sent on to Medicare part B. Currently Medicare is picking up the entire copay and I end up owing nothing for Pulmozyme.
What you are trying to do makes total sense to me. What I'm unsure of is whether your plan from previous employment is primary or secondary. If medicare is your primary it would be easy to bill Pulmozyme, Tobi, NAC etc to Medicare Part B first and let them pick up the bulk of it, then bill your private insurance for whatever is left after Medicare pays. So IF medicare is currently your primary, it would be very smart to have them pay on these first and would totally achieve your goal of lightening the load of your self-insured plan. If your private insurance is your primary, then prescriptions would have to be billed through them first unfortunately. Medicare has guidelines for deciding whether they are the primary payer or secondary. If they are secondary, they will not pay for things unless it has been billed through your primary first. I'm sorry if I'm being redudant. You probably already know which is primary and which is secondary. But if you have any questions about it you can call the Medicare Coordination of Benefits Contractor at 800-999-1118. I had to call them when I was on Cobra and things were a little confusing. They were actually quite helpful. Medicare became my primary during that time because my insurance was not based on current employment. Which is why I'm thinking it's possible that Medicare is your primary. In which case they should be paying for these uber expensive drugs!
Sorry for the rambling, I hope I've made sense! Like Jen said, keep the questions coming and hopefully we can help get it figured out!
autumn
What you are trying to do makes total sense to me. What I'm unsure of is whether your plan from previous employment is primary or secondary. If medicare is your primary it would be easy to bill Pulmozyme, Tobi, NAC etc to Medicare Part B first and let them pick up the bulk of it, then bill your private insurance for whatever is left after Medicare pays. So IF medicare is currently your primary, it would be very smart to have them pay on these first and would totally achieve your goal of lightening the load of your self-insured plan. If your private insurance is your primary, then prescriptions would have to be billed through them first unfortunately. Medicare has guidelines for deciding whether they are the primary payer or secondary. If they are secondary, they will not pay for things unless it has been billed through your primary first. I'm sorry if I'm being redudant. You probably already know which is primary and which is secondary. But if you have any questions about it you can call the Medicare Coordination of Benefits Contractor at 800-999-1118. I had to call them when I was on Cobra and things were a little confusing. They were actually quite helpful. Medicare became my primary during that time because my insurance was not based on current employment. Which is why I'm thinking it's possible that Medicare is your primary. In which case they should be paying for these uber expensive drugs!
Sorry for the rambling, I hope I've made sense! Like Jen said, keep the questions coming and hopefully we can help get it figured out!
autumn
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RytheStunner
Guest
I was solely on Medicare + Medicare supplemental plan for over a year, and my Cayston was being covered. The only caveat is I wasn't eligible for the small manufacturer's discount since I was on Medicare, so it cost me about $75/month. Since Medicare supplemental typically only covers things that Medicare itself would also cover, I believe they did cover it.
Ry, did you have part D insurance as well? I know Cayston is covered under that plan ( actually, it depends on the plan you choose for your Rx) , I was approved for it under my part D insurance, but not part B, but that was about a year ago. Also, for those who do not make much income, you can qualify for extra help with your Rx's through Medicare, which usually means they will pick up most of the tab for most meds. I think it kind of acts like Medicaid in that respect, because I believe that the state helps with the costs on the extra help program. If it is indeed covered by part B, I am going to be very happy! Will def check it out
Jenn 40 wcf
Jenn 40 wcf
Hello Autumn, thank you and everyone else for the info regarding Medicare Part B and nebulized medication. Sorry for not being clear about my ins. and Medicare. My wife and I are now both retired and have secondary ins. with our previous employer (same employer) of 40 yrs. I have been on my brides ins. since I retired in 2004. Now that she retired this past April, Medicare A & B are now primary for me. My drug plan is through my previous employer and no ties to Medicare. In the Medicare hand book it states Drugs used with a nebulizer in the home are covered under part B. as regards to Cystic Fibrosis. It should state approved drugs!! I am just trying to get a clear understanding of how this would work with my secondary ins. that has my drug coverage. As stated previously trying to lighten the load of my secondary ins. since it is self funded.
Thanks again for the info. Hope this will help others also.
On another topic regarding medication under part B as regards to transplant, this is very confusing as to how it is written. I beleive it will cover transplant rejection drugs even if you were just enrolled, and had primary ins. that the transplant was covered under.
Thanks again for the info. Hope this will help others also.
On another topic regarding medication under part B as regards to transplant, this is very confusing as to how it is written. I beleive it will cover transplant rejection drugs even if you were just enrolled, and had primary ins. that the transplant was covered under.
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RytheStunner
Guest
I do have Part D. It's possible my Cayston was covered under that. I haven't been on Cayston for very long and Foundation Care took care of most of that behind the scenes. I know for a fact Pulmozyme and TOBI/Tobramycin were covered under Part B (they refused to cover it under Part D). I used to be on extra help, but no longer qualify. I also make too much/have too many assets to qualify for Medicaid.
Great Scan, thanks for the clarification! Now I have more concrete advice for you.
So since Medicare is your primary you should absolutely have them paying whatever meds they will cover before your private secondary pays. This means for sure your Tobi, Pulmozyme, and acetylcysteine (per Jenn saying they cover it). This would lift A LOT of the burden from your private plan and achieve exactly what you are going for. You can just continue filling all your others through your private plan.
Last year when I was on a COBRA plan and Medicare was my primary I was in the exact same situation as you. I had my private insurance that had my prescription coverage, so I didn't need a Part D plan through Medicare. Here's what I did. I got my Pulmozyme through CF Services and all my others (not covered by part B) at Walgreens. Walgreens only had my private insurance info and billed all my prescription through them. CF Services had my Medicare info and billed them for the Pulmozyme, then they sent the copay of what Medicare didn't cover to my private insurance.
So it may be tough to get it all sorted out but I think it would be worth it in the long run. I'm thinking maybe you could do something similar to what I did. Fill the "big" ones through CF Services and have them bill Part B and then your private. Then fill your others using your private insurance. The only reason I am suggesting CF Services is because they can bill to part B and then bill a secondary insurance. I'm not sure if a local pharmacy can do that. If you could find a local pharmacy that can bill Part B then that should work as well. You could also probably give CF Services a call and ask them about what part B will cover and ask about getting your meds through them.
As to the Cayston, I get that from CF Services as well and what I was told by them is that it is NOT covered by part B. I *think* they would know that information so I'm guessing it's accurate. So once you get everything straightened out Cayston should be the only really high dollar drug that your private insurance has to cover. And hopefully they add it to part B soon.
Sorry, I've rambled again. I really hope I'm helping even if it's just a tiny bit!
Let us know if you have more questions!
So since Medicare is your primary you should absolutely have them paying whatever meds they will cover before your private secondary pays. This means for sure your Tobi, Pulmozyme, and acetylcysteine (per Jenn saying they cover it). This would lift A LOT of the burden from your private plan and achieve exactly what you are going for. You can just continue filling all your others through your private plan.
Last year when I was on a COBRA plan and Medicare was my primary I was in the exact same situation as you. I had my private insurance that had my prescription coverage, so I didn't need a Part D plan through Medicare. Here's what I did. I got my Pulmozyme through CF Services and all my others (not covered by part B) at Walgreens. Walgreens only had my private insurance info and billed all my prescription through them. CF Services had my Medicare info and billed them for the Pulmozyme, then they sent the copay of what Medicare didn't cover to my private insurance.
So it may be tough to get it all sorted out but I think it would be worth it in the long run. I'm thinking maybe you could do something similar to what I did. Fill the "big" ones through CF Services and have them bill Part B and then your private. Then fill your others using your private insurance. The only reason I am suggesting CF Services is because they can bill to part B and then bill a secondary insurance. I'm not sure if a local pharmacy can do that. If you could find a local pharmacy that can bill Part B then that should work as well. You could also probably give CF Services a call and ask them about what part B will cover and ask about getting your meds through them.
As to the Cayston, I get that from CF Services as well and what I was told by them is that it is NOT covered by part B. I *think* they would know that information so I'm guessing it's accurate. So once you get everything straightened out Cayston should be the only really high dollar drug that your private insurance has to cover. And hopefully they add it to part B soon.
Sorry, I've rambled again. I really hope I'm helping even if it's just a tiny bit!
Let us know if you have more questions!
dream2live
New member
I would check with Medicare Part B online/phone/etc. and try to get all u can before "obamacare" takes effect. People with chronic diseases like CF will be the first to feel the effects of trying to get meds filled/approved/etc.
jmetzinger
New member
I just went through this whole mess and had delays in getting my meds. I was told the meds weren't covered... when actually all I needed was a Prior Authorization from my doctor - my pharmacy (CVS) and the first Medicare agent I spoke with did not share this information with me. I would double check that a Prior Authorization is not the answer.
Also, I switched my meds to CF Services Pharmacy, they ended up doing a lot of this work for me on the subsequent meds where the other pharmacy told me they couldn't do anything for me. I now only get my nebulizers from CF pharmacy.
Also, I switched my meds to CF Services Pharmacy, they ended up doing a lot of this work for me on the subsequent meds where the other pharmacy told me they couldn't do anything for me. I now only get my nebulizers from CF pharmacy.