Aa
medicare
I have medicare in California I will enroll in it next month,I have liver transplant with hcv and cirrhosis ,I need to find out how medicare and if medicare pay for sovaldi and olysio.Tank you
And squid...cool handle name....meant to add in my original post. My supplemental monthly cost for my Part D drug plan is $42. I also have supplemental medical which costs $168 a month. Medicare takes their Part A and B medical plan out of your Medicare check and it costs about $105. Part A and B pay for approximately 80% of "covered" medical costs...that why you need a supplemental medical plan for that unpaid 20%.
Medicare is a Federal Program and is the same in each state. Medicaid is different state by state.
Don't know how much your Medicare check would be and what your state regulations for Medicaid but here, for me, in the State of Indiana, my Medicare check is just slightly over what income level I would need to be at to get Medicaid. There is nothing stopping me from applying for the Medicaid but I would have to pay a "spend down" dollar amount which would leave me in a worse financial situation. The amount I received in Medicare is just enough to cover my monthly expenses but is also to much to qualify for any other optional state programs.
Medicare is a federal program. You have the option of getting medical coverage through them. This is Part A & B. It will not cover drugs unless like in the case of transplant patients it is deemed as life saving.
Sovaldi and Riba not deemed "life saving" and are not covered under Part A&B....you will have to get the Part D coverage from one of the companies who offer it. All major insurers offer it....you can go to medicare.org and see what plans they suggest for your part D but that plan , the part D, is not provided for by the government...it come through a supplemental insurer, BUT here's the hook, Medicare can pay that supplement company for the Part D supplemental for you out of your Medicare check.
I think that is the most confusing thing about Medicare....they list all of these options....C, D, F,G, H but really aren't that clear on how it all works.
I am lucky because my sister-in-law is an Administrator for 2nd largest insurance companies in the US...and it took her several times of explaining it to me for me to get.....
When they called me about my sovaldi / riba they told me I had no Part D Medicare but I knew I did because of my conversations with my insurer so I basically had to school the agent who was calling me.
And even when you have a life saving procedure,,,like a transplant,..there is one drug you HAVE to take for 90 days and it isn't covered my Medicare although Medicare does cover your life time of immenos. The transplant financial person will try to get a "grant" for you to pay for $1000 per month copay. So there is all sorts of ifs ands and buts.
So yes, the Medicare lady was right...the only thing she wasn't saying to you was that the sovaldi / riba is covered under your Part D which you have to purchase through a supplemental Insurer and which they can pay for you out of your Medicare check. But you WILL NEVER GET a Part D insurance card from the government. You WILL GET a Part D supplemental Medicare insurance card from whatever optional provider you choose.
Clear as mud right? All of this....no matter what kind of insurance we do or don't have is extremely confusing to the general masses....I've always said this as I've watched my mother and other elderly people keep track of all this information. When you least have the energy to figure all of this out is when you have to be your sharpest or be lucky like I am to have someone in the business that knows what they are talking about.
And whether you have Medicare or not...do you have regular insurance...??? Once prescribed you can still apply through panfoundation and see what your options are. Good luck.
And you are only 54. The normal age for Medicare sign-up is 65 unless you are on disability. If you are...then that is a whole other scenario that I don't have complete information on,
Good luck....you can email me.
The panfoundation.org ,,,,,one my doctor prescribed the medication for me....are taking care of my sovaldi / riba costs. You have to wait though until they prescribe it for you before you can get any personal qualification information. The do ask you about assets and other income and if you are on Medicaid.
Medicare is a Federal Program and is the same in each state. Medicaid is different state by state.
Don't know how much your Medicare check would be and what your state regulations for Medicaid but here, for me, in the State of Indiana, my Medicare check is just slightly over what income level I would need to be at to get Medicaid. There is nothing stopping me from applying for the Medicaid but I would have to pay a "spend down" dollar amount which would leave me in a worse financial situation. The amount I received in Medicare is just enough to cover my monthly expenses but is also to much to qualify for any other optional state programs.
Medicare is a federal program. You have the option of getting medical coverage through them. This is Part A & B. It will not cover drugs unless like in the case of transplant patients it is deemed as life saving.
Sovaldi and Riba not deemed "life saving" and are not covered under Part A&B....you will have to get the Part D coverage from one of the companies who offer it. All major insurers offer it....you can go to medicare.org and see what plans they suggest for your part D but that plan , the part D, is not provided for by the government...it come through a supplemental insurer, BUT here's the hook, Medicare can pay that supplement company for the Part D supplemental for you out of your Medicare check.
I think that is the most confusing thing about Medicare....they list all of these options....C, D, F,G, H but really aren't that clear on how it all works.
I am lucky because my sister-in-law is an Administrator for 2nd largest insurance companies in the US...and it took her several times of explaining it to me for me to get.....
When they called me about my sovaldi / riba they told me I had no Part D Medicare but I knew I did because of my conversations with my insurer so I basically had to school the agent who was calling me.
And even when you have a life saving procedure,,,like a transplant,..there is one drug you HAVE to take for 90 days and it isn't covered my Medicare although Medicare does cover your life time of immenos. The transplant financial person will try to get a "grant" for you to pay for $1000 per month copay. So there is all sorts of ifs ands and buts.
So yes, the Medicare lady was right...the only thing she wasn't saying to you was that the sovaldi / riba is covered under your Part D which you have to purchase through a supplemental Insurer and which they can pay for you out of your Medicare check. But you WILL NEVER GET a Part D insurance card from the government. You WILL GET a Part D supplemental Medicare insurance card from whatever optional provider you choose.
Clear as mud right? All of this....no matter what kind of insurance we do or don't have is extremely confusing to the general masses....I've always said this as I've watched my mother and other elderly people keep track of all this information. When you least have the energy to figure all of this out is when you have to be your sharpest or be lucky like I am to have someone in the business that knows what they are talking about.
And whether you have Medicare or not...do you have regular insurance...??? Once prescribed you can still apply through panfoundation and see what your options are. Good luck.
And you are only 54. The normal age for Medicare sign-up is 65 unless you are on disability. If you are...then that is a whole other scenario that I don't have complete information on,
Good luck....you can email me.
The panfoundation.org ,,,,,one my doctor prescribed the medication for me....are taking care of my sovaldi / riba costs. You have to wait though until they prescribe it for you before you can get any personal qualification information. The do ask you about assets and other income and if you are on Medicaid.
Thank you all for your answer ,I am geno tipe 1a ,when I spoke to the lady at medicare she told me that when I enroll in medicare next month we she make sure sovaldi and olysio will be pre approved by medicare, so I don't understand if when I will enroll with insurance company I will automatically get sovaldi and olysio I don't think .I am worry about my liver I am cirrhosis stage 4 after 4 year's of transplant .Not good .Well thank you again for all yours answer I will keep up the war to kill the ******* in side me for over the last 30 years .You all have a great day and a wonderful week end .
Best wishes on getting covered. Don't get discouraged and be willing to "fight" to get treatment if necessary
Medicare insurance may depend on urgency for starting treatment ASAP, your current medical condition and contraindications. Your doctor will need prior approval. Most likely have to answer detailed justification questions in a proscribed order. Each or some will either eliminate this tx or direct you to the next related question until the answer is YES or NO. It will be Off-Label and If not listed on formulary include off formulary request criteria. It's import you and your doctor provide all the details and test results correctly.. You may be denied and have to appeal as some members here have had to do to get covered.
Patient Access Network (PAN) can help provide assistance to those on Medicare up to $7,000 toward copays. Some of the deductibles donut hole MAY also be able to be covered depending on how prescription are structured. Household income must fall below 500% of the Federal Poverty Level. Open for applications as of the date and time of this comment
http://www.gilead.com/responsibility/us-patient-access/support%20path%20for%20sovaldi
Gilead will provide support to the Patient Access Network (PAN) Foundation, an independent non-profit organization that provides assistance for eligible federally-insured and privately-insured patients who need help covering out-of-pocket medication costs.
Program Status Open as of the time of this comment
https://www.panfoundation.org/hepatitis-c
Program Status
Open - We are accepting applications for new and renewal patients. If your application for assistance is approved you can begin receiving funding immediately.
Maximum Award Level
$7,000 per year
Eligibility Criteria
Patient should be insured and insurance must cover the medication for which patient seeks assistance.
The medication must treat the disease directly.
Patient must reside and receive treatment in the United States.
Patient’s income must fall below 500% of the Federal Poverty Level.
Click here for Federal Poverty Guidelines
Get Help With Your Treatment
Apply Online (Click Here) or call 1-866-316-PANF (7263)
Information About the Disease
Hepatitis C, like other forms of hepatitis, causes inflammation of the liver. The hepatitis C virus is transferred primarily through blood, and is more persistent than hepatitis A or B. High-risk groups are people who inject drugs, people who receive transfusions of unscreened blood, dialysis patients and people who have unprotected sex with multiple sex partners. Hepatitis C is also treated with antiviral medications.
For more information visit the Hepatitis Foundation International website, or call 1-800-891-0707
https://www.panfoundation.org/fundingapplication/faq.php
PAN Foundation can consider for payment any co-payment, deductible, or co-insurance amount for medications that are used to treat the disease for which you have been awarded assistance. Medications that treat the side effects of your diagnosis are not covered, and charges for office visits and administration are not typically covered.
http://www.olysio.com/support/financial-assistance
I Have Government-Supported (Medicare, Medicaid, TRICARE) or Commercial Insurance Health Coverage.
If you still can't afford OLYSIO™, the following foundation support may be available:
Patient Access Network Foundation
phone number l panfoundation.org
Patient Advocate Foundation
phone number l patientadvocate.org
Medicare insurance may depend on urgency for starting treatment ASAP, your current medical condition and contraindications. Your doctor will need prior approval. Most likely have to answer detailed justification questions in a proscribed order. Each or some will either eliminate this tx or direct you to the next related question until the answer is YES or NO. It will be Off-Label and If not listed on formulary include off formulary request criteria. It's import you and your doctor provide all the details and test results correctly.. You may be denied and have to appeal as some members here have had to do to get covered.
Patient Access Network (PAN) can help provide assistance to those on Medicare up to $7,000 toward copays. Some of the deductibles donut hole MAY also be able to be covered depending on how prescription are structured. Household income must fall below 500% of the Federal Poverty Level. Open for applications as of the date and time of this comment
http://www.gilead.com/responsibility/us-patient-access/support%20path%20for%20sovaldi
Gilead will provide support to the Patient Access Network (PAN) Foundation, an independent non-profit organization that provides assistance for eligible federally-insured and privately-insured patients who need help covering out-of-pocket medication costs.
Program Status Open as of the time of this comment
https://www.panfoundation.org/hepatitis-c
Program Status
Open - We are accepting applications for new and renewal patients. If your application for assistance is approved you can begin receiving funding immediately.
Maximum Award Level
$7,000 per year
Eligibility Criteria
Patient should be insured and insurance must cover the medication for which patient seeks assistance.
The medication must treat the disease directly.
Patient must reside and receive treatment in the United States.
Patient’s income must fall below 500% of the Federal Poverty Level.
Click here for Federal Poverty Guidelines
Get Help With Your Treatment
Apply Online (Click Here) or call 1-866-316-PANF (7263)
Information About the Disease
Hepatitis C, like other forms of hepatitis, causes inflammation of the liver. The hepatitis C virus is transferred primarily through blood, and is more persistent than hepatitis A or B. High-risk groups are people who inject drugs, people who receive transfusions of unscreened blood, dialysis patients and people who have unprotected sex with multiple sex partners. Hepatitis C is also treated with antiviral medications.
For more information visit the Hepatitis Foundation International website, or call 1-800-891-0707
https://www.panfoundation.org/fundingapplication/faq.php
PAN Foundation can consider for payment any co-payment, deductible, or co-insurance amount for medications that are used to treat the disease for which you have been awarded assistance. Medications that treat the side effects of your diagnosis are not covered, and charges for office visits and administration are not typically covered.
http://www.olysio.com/support/financial-assistance
I Have Government-Supported (Medicare, Medicaid, TRICARE) or Commercial Insurance Health Coverage.
If you still can't afford OLYSIO™, the following foundation support may be available:
Patient Access Network Foundation
phone number l panfoundation.org
Patient Advocate Foundation
phone number l patientadvocate.org
What Hector is saying above for post transplant patients is correct. And he knows what he is talking about.
I will add some info for pre-transplant patients or just patients on Medicare who aren't getting a transplant at this point but might be reading this post. It is a little different. After the transplant it becomes part of your on going care. I am pre-transplant.
Part D is for your drugs. That is not provided by Medicare. You get it from a supplemental company like Aetna, Blue Cross, Humana, the one through AARP, etc.... They are your Medicare Part D. You will have a co-pay which can be quite expensive...anywhere from $3000 to $14000 dollars a month.
I am on Medicare. No way in h that I could afford that. With Medicare there is a period of time at the first of year where you fall into what they call a donut hole and you have to meet a deductible before you see a decrease in your co-pays. Example. I take Xifanan. In donut hole my co-pay is $580. Once I meet my deductible which is $2900 I come out of the donut hole period and my copay for same drug is $70.
I got approved for Sovaldi / Riba through the drug company for Sovaldi / Riba. Once my drug participation was okayed the drug company called me immediately and got my paperwork in the works. I still have to deal with my other co-pays.
If your only source of income like me is Medicare it is virtually impossible to afford some of these drugs without assistance programs. I tried to get assistance for the Xifanan but could not because I receive Medicare and was told anyone on Medicare or Medicaid could not through their company...Salix...receive assistance. I don't really understand that since this is a drug that can be purchased in Canada at full price for $170. Here the full price is slightly over $1300. So get help where you can get it.
Good luck with your transplant. I am trying to kill this demon prior to my transplant...will be on Sovaldi / Riba 24 weeks. It doesn't take me off the transplant list but sets me to the margin while on treatment.....hope I can make it. Hector is my hero and I have a positive attitude.. Hard not to when you hear some of the stories on here and you get the positive support everyone on here provides.
I will add some info for pre-transplant patients or just patients on Medicare who aren't getting a transplant at this point but might be reading this post. It is a little different. After the transplant it becomes part of your on going care. I am pre-transplant.
Part D is for your drugs. That is not provided by Medicare. You get it from a supplemental company like Aetna, Blue Cross, Humana, the one through AARP, etc.... They are your Medicare Part D. You will have a co-pay which can be quite expensive...anywhere from $3000 to $14000 dollars a month.
I am on Medicare. No way in h that I could afford that. With Medicare there is a period of time at the first of year where you fall into what they call a donut hole and you have to meet a deductible before you see a decrease in your co-pays. Example. I take Xifanan. In donut hole my co-pay is $580. Once I meet my deductible which is $2900 I come out of the donut hole period and my copay for same drug is $70.
I got approved for Sovaldi / Riba through the drug company for Sovaldi / Riba. Once my drug participation was okayed the drug company called me immediately and got my paperwork in the works. I still have to deal with my other co-pays.
If your only source of income like me is Medicare it is virtually impossible to afford some of these drugs without assistance programs. I tried to get assistance for the Xifanan but could not because I receive Medicare and was told anyone on Medicare or Medicaid could not through their company...Salix...receive assistance. I don't really understand that since this is a drug that can be purchased in Canada at full price for $170. Here the full price is slightly over $1300. So get help where you can get it.
Good luck with your transplant. I am trying to kill this demon prior to my transplant...will be on Sovaldi / Riba 24 weeks. It doesn't take me off the transplant list but sets me to the margin while on treatment.....hope I can make it. Hector is my hero and I have a positive attitude.. Hard not to when you hear some of the stories on here and you get the positive support everyone on here provides.
You should talk to your hepatologist who will be treating your hepatitis C or the transplant center's financial counselor who has handled all over your transplant center's health insurance claims so far. They are aware of your health coverage and will be the one that submits the forms to Medicare. Medicare will then submit the part they don't pay to your secondary health insurance company. Have the transplant financial counselor tell you what your co-pay will be if any.
The transplant center is the one that is responsible for getting approval for payment of all of your medical needs. Curing hep-C post transplant is part of your health care needs at this point.
Your transplant center (like mine UCSF) is probably already treating other Medicare patients with sovaldi and olysio as many liver transplant patients like you and me became disabled on our road to transplant.
Congratulations on your transplant! Best of luck curing your hep C.
Hector
The transplant center is the one that is responsible for getting approval for payment of all of your medical needs. Curing hep-C post transplant is part of your health care needs at this point.
Your transplant center (like mine UCSF) is probably already treating other Medicare patients with sovaldi and olysio as many liver transplant patients like you and me became disabled on our road to transplant.
Congratulations on your transplant! Best of luck curing your hep C.
Hector
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