Cayston & Medicare

[melx]

Hi everyone,
Have not posted in a while and hope 2012 is treating you all well so far. I am trying to understand Cayston and Medicare. Seems like I have heard from some that Cayston is covered under part B and others tell me they are covered under part D.
If you are on Cayston and covered through Medicare which part is paying it for you? If it is through Part D than I am assuming you are immediately in the Donut hole right?
I am so confused at this point.

 

[melx]

Hi everyone,
Have not posted in a while and hope 2012 is treating you all well so far. I am trying to understand Cayston and Medicare. Seems like I have heard from some that Cayston is covered under part B and others tell me they are covered under part D.
If you are on Cayston and covered through Medicare which part is paying it for you? If it is through Part D than I am assuming you are immediately in the Donut hole right?
I am so confused at this point.

 

[triples15]

Hi Mel,

I only have part B (no part D)and it does not yet cover Cayston. It is my understanding that it will eventually be added under part B, like Pulmozyme and Tobi. I'm really hoping they add it soon!! Medicare is my secondary now but my primary has an astronomical copay/deductible so it would really help if Medicare would pick it up!

I do think I have read that some people's part D has covered Cayston, but it depends on the plan. I think you are correct, I can't see how it wouldn't immediately put you in the donut hole?

I agree, it is all VERY confusing!

Good luck and take care,

Autumn

 

[triples15]

Hi Mel,

I only have part B (no part D)and it does not yet cover Cayston. It is my understanding that it will eventually be added under part B, like Pulmozyme and Tobi. I'm really hoping they add it soon!! Medicare is my secondary now but my primary has an astronomical copay/deductible so it would really help if Medicare would pick it up!

I do think I have read that some people's part D has covered Cayston, but it depends on the plan. I think you are correct, I can't see how it wouldn't immediately put you in the donut hole?

I agree, it is all VERY confusing!

Good luck and take care,

Autumn

 

[JustDucky]

I have medicare as my primary, along with part D insurance. Autumn is correct as far as part B not covering Cayston yet....I have been waiting for that golden moment since it got FDA approval for treatment of PA in CF. Depending on the type of coverage that your part D has, it may be covered, but considering that it is a brand and costs a fortune, it would immediately put you in that coverage gap (the doughnut hole). I guess the good thing is that you would hit catastrophic coverage (after you have paid 4,000 plus dollars out of pocket) very quickly and then the insurance would pick it up again with you paying 5% of the cost (would be about 250 if Cayston costs 5,000). If you can afford that, then great <img src="i/expressions/face-icon-small-smile.gif" border="0"> Check into the drug programs that Cayston has, they may be able to help some.
Hope this helps...
Jenn 40 w/CF

 

[JustDucky]

I have medicare as my primary, along with part D insurance. Autumn is correct as far as part B not covering Cayston yet....I have been waiting for that golden moment since it got FDA approval for treatment of PA in CF. Depending on the type of coverage that your part D has, it may be covered, but considering that it is a brand and costs a fortune, it would immediately put you in that coverage gap (the doughnut hole). I guess the good thing is that you would hit catastrophic coverage (after you have paid 4,000 plus dollars out of pocket) very quickly and then the insurance would pick it up again with you paying 5% of the cost (would be about 250 if Cayston costs 5,000). If you can afford that, then great <img src="i/expressions/face-icon-small-smile.gif" border="0"> Check into the drug programs that Cayston has, they may be able to help some.
Hope this helps...
Jenn 40 w/CF

 

[stephen]

Just turned 70 and went on Medicare. (Previously I had insurance provided by my employer that covered Cayston for a $50 co-payment.)

I now have a Medicare "Equivalent Rx" plan provided by my wife's former employer. Cayston is covered. The co-pay for the first month's supply, which was just delivered, was $1454. This puts me into the "donut hole".

My understanding is that the next delivery will cost something over $2000. Once my total yearly out of pocket drug costs reach $4700, my co-payments will drop to 5% of the drug price. Supposedly, my plan will reimburse these 5% payments at the end of the year.

I am fortunate that Cayston exists, and although these costs hurt I can manage to cover them, thank G-d.

There may be better drug plans but for now I thankful for this coverage.

Best wishes and good luck to all.

Stephen
Just turned 70, Finally diagnosed at 63, FEV1 of 47% - Otherwise in good health!

 

[stephen]

Just turned 70 and went on Medicare. (Previously I had insurance provided by my employer that covered Cayston for a $50 co-payment.)

I now have a Medicare "Equivalent Rx" plan provided by my wife's former employer. Cayston is covered. The co-pay for the first month's supply, which was just delivered, was $1454. This puts me into the "donut hole".

My understanding is that the next delivery will cost something over $2000. Once my total yearly out of pocket drug costs reach $4700, my co-payments will drop to 5% of the drug price. Supposedly, my plan will reimburse these 5% payments at the end of the year.

I am fortunate that Cayston exists, and although these costs hurt I can manage to cover them, thank G-d.

There may be better drug plans but for now I thankful for this coverage.

Best wishes and good luck to all.

Stephen
Just turned 70, Finally diagnosed at 63, FEV1 of 47% - Otherwise in good health!

 

[melx]

Thank you all for your responses. I think my part D will cover it, just not sure at what %. I cant believe this Donut hole thing was ever a good idea. Those of us with CF have had to deal with complex insurance issues our whole life. We are usually well versed and can easily understand the ins and out of insurance - but this Donut hole takes the confusion cake away from any other issue I have ever dealt with. I cant imagine the confusion and frustration for those (especially seniors) who have rarely if ever had to deal with major insurance issues.
What a mess. I cant wait for the Donut hole to be phased out.
And WHY is Tobi paid under part B but not Cayston? That makes no sense..... except I am thinking supplemental (medigap) insurers had a say in this decision. I am pretty sure they are not eager to pay the 20% of any of our inhaled abx; and maybe they learned a lesson with Tobi so now Cayston gets shot down.
Thanks for letting me vent folks.

 

[melx]

Thank you all for your responses. I think my part D will cover it, just not sure at what %. I cant believe this Donut hole thing was ever a good idea. Those of us with CF have had to deal with complex insurance issues our whole life. We are usually well versed and can easily understand the ins and out of insurance - but this Donut hole takes the confusion cake away from any other issue I have ever dealt with. I cant imagine the confusion and frustration for those (especially seniors) who have rarely if ever had to deal with major insurance issues.
What a mess. I cant wait for the Donut hole to be phased out.
And WHY is Tobi paid under part B but not Cayston? That makes no sense..... except I am thinking supplemental (medigap) insurers had a say in this decision. I am pretty sure they are not eager to pay the 20% of any of our inhaled abx; and maybe they learned a lesson with Tobi so now Cayston gets shot down.
Thanks for letting me vent folks.

 

[JustDucky]

TOBI is under part B because it has to be delivered via durable medical equipment (the nebulizer), that's why pulmozyme, duonebs, atrovent, albuteral nebs are also covered. They are a bit slow as far as putting Cayston on part B coverage.....I wonder how long it took for them to approve TOBI once it came out for part B coverage. It was also a bit more complex before January 2006, there were no part D plans that I am aware of, so there really was only part B coverage for meds if they met certain criteria. I am sure that there was pressure for any type of coverage on a med as expensive as TOBI for CF'ers, so expensive that a CF'er on straight Medicare would not be able to afford this crucial medication otherwise. Now that there is part D and coverage of Cayston is possible (depending on the plan), I wonder if that is why it is taking so long to get it covered under part B....Of course, I am just speculating <img src="i/expressions/face-icon-small-wink.gif" border="0"> Anything with Medicare is more complex than it should be...I too will be very thankful once the doughnut hole is finally phased out (supposed to happen by 2020). It will make coverage of very expensive meds a whole lot doable.

Jenn 40 w/CF

 

[JustDucky]

TOBI is under part B because it has to be delivered via durable medical equipment (the nebulizer), that's why pulmozyme, duonebs, atrovent, albuteral nebs are also covered. They are a bit slow as far as putting Cayston on part B coverage.....I wonder how long it took for them to approve TOBI once it came out for part B coverage. It was also a bit more complex before January 2006, there were no part D plans that I am aware of, so there really was only part B coverage for meds if they met certain criteria. I am sure that there was pressure for any type of coverage on a med as expensive as TOBI for CF'ers, so expensive that a CF'er on straight Medicare would not be able to afford this crucial medication otherwise. Now that there is part D and coverage of Cayston is possible (depending on the plan), I wonder if that is why it is taking so long to get it covered under part B....Of course, I am just speculating <img src="i/expressions/face-icon-small-wink.gif" border="0"> Anything with Medicare is more complex than it should be...I too will be very thankful once the doughnut hole is finally phased out (supposed to happen by 2020). It will make coverage of very expensive meds a whole lot doable.

Jenn 40 w/CF

 

[melx]

Good thoughts Jenn. I had not thought about the fact that there was no part D when Tobi came out and probably the same for Pulmozyme too. It makes me wonder if Cayston will ever be covered under part B, since there is now a specific program for Drug coverage.

 

[melx]

Good thoughts Jenn. I had not thought about the fact that there was no part D when Tobi came out and probably the same for Pulmozyme too. It makes me wonder if Cayston will ever be covered under part B, since there is now a specific program for Drug coverage.