![]() This bleak situation is currently set to improve in 2025 when the reforms passed under Biden's massive infrastructure bill take effect and maximum out-of-pocket drug costs under Medicare will be cut to $2000/year. Your current GI will not be covered (unless you are already on Kaiser insurance and seeing a Kaiser doctor). The cheapest Medicare coverage for Stelara that I have found is offered through Kaiser Medicare Advantage plans, but they have the disadvantage that you must switch to Kaiser doctors. It considers these co-pay plans paid for by the drug companies to be a form of kickback. One minor clarification is that Janssen CarePath co-pay program would be perfectly happy to cover Medicare plans, but the Federal government won't allow it. You have hit on the sad reality facing anyone on Medicare who needs a very expensive specialty drug. Poor s almost 26k per dose.Ĭlick to expand.No, you are not missing anything. My insurance covered it no questions asked. I hope after this one no more surgeries!! I have another surgery later this month to remove a stricture in my terminal ileum at the anastomosis at the spot were I had the ileostomy. I had prostate cancer surgery 3 months ago and I had a bad relapse, very bad proctitis, with prednisone, mesalamine etc etc before the Stelara. My Dr always told me that he was always surprised on how good my labwork results were compared to how bad the mucosa was. I stopped Remi and they went up to a little more than 200. When I was on Remicade my levels went down from almost 600 to the forties. The Dr told me that he will check the Calprotectin levels in 4 months. I feel fine so I assume I am in remission. But it was easy and everything went smoothly. Since this thing is SOOOOO expensive I was a little bit freaked out when I injected it. Nope, I had the loading dose and then 2 months later I injected myself. ![]() Apparently something to do with medicare. The damnedest thing is that since being on a medicare advantage plan, the insurance company is paying the provider more than they billed. I had considered the use of a specialty pharmacy at one time but they also were throwing around the $20k+ number. Turns out the infusion center pharmacy purchases the Stelara from a drug wholesaler, hence the "low cost". The contract price between the provider and the insurance co has ranged from $3,900 to $7,000 while I was covered by a commercial plan prior to turning age 65. between $6,000 and $11,000 for the Stelara over the course of the 20 injections that I've had since 2018. The infusion center pharmacy has billed the insurance Co. I built a spreadsheet of all the various cost data presented in the "Explanation of Benefits" documents. I've had 20 injections thus far all administered by a hospital infusion center and billed to my medical plan. It’s close to $23000 per shot right now per the drug insurance claims for my kiddo on Stelara every 4 weeks" "Retail cost varies by specialty pharmacy. Still lots of questions.but if the retail cost per injection is $15,000 and I get six injection per year, my total out-of-pocket would be $10,800.I think, haha. The asterisk * - CMS Mandated Changes for 2022 My plan description includes the footnote "After beneficiary's yearly out-of-pocket drug costs reach $7,050*, beneficiary pays the greater of 5% coinsurance or $3.95* copay for generics and $9.85* copay for all other drugs. The coverage gap thresholds are $4,430 and $7,050 which is apparently the medicare standard threshold values. For my particular plan the copay is 33% during the Initial Coverage Stage, 25% during the Coverage Gap Stage, and 5% during the Catastrophic Stage. So some plans are better than the medicare standard. ![]() I understand that MAPD plans must meet a minimum co-pay standard establish by Medicare. If a drug plan benefit, there is a confusing set of rules to determine the copay. Stelara is in its formulary but not sure if it is listed as a drug plan benefit or a now defunct medical plan benefit. So, I'm looking at a particular MAPD plan offered through the company from which I retired. My provider was kind enough to turn-over a sample provided to them by a pharmaceutical company to get me through the end of the year. So currently, I no longer have coverage for Stelara. My existing drug plan, which is not part D, does not cover injectable medications. That all changed October 15 when Medicare added Stelara to the "self administered drug" exclusion list. This was the case with the commercial plan I had prior to turning 65 and the Medicare Advantage Plan I enrolled in after turning 65. My insurance was such that both the initial dose administered by infusion and the maintenance doses administered by subcutaneous injection were covered by my medical plan vs my drug plan. ![]() So, I finally made 65 years old May 2021. ![]()
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