Medicare's coverage for Stelara: A review

Medicare's coverage for Stelara: A review

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Stelara and the Cash Outlay: Navigating Medicare Part D and Advantage Plans

Stelara, a medication for psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis, might be covered under Medicare Part D. But, what does that mean for the cost you'll have to shell out? Let's dissect this medical jargon!

Glossary of Medicare Slang:

1. Out-of-pocket Cost: Amount you need to cough up for care when Medicare doesn't cover everything. This could be deductibles, coinsurance, copayments, and monthly premiums.
2. Premium: Money you pay monthly to secure Medicare coverage.
3. Deductible: Annual amount you must spend out of pocket before Medicare starts paying for your treatments.
4. Coinsurance: Percentage of treatment costs you are responsible for. For Medicare Part B, it's 20%.
5. Copayment: Fixed amount you pay when receiving certain treatments, usually applies to prescription drugs.

So, does Medicare cover Stelara?

Medicare Part D generally does, as it covers prescription drugs, making Stelara a better fit there rather than Part B.

Medicare Advantage (Part C) plans may provide drug coverage (Part D) as part of a combined package. These plans usually cover prescriptions like Stelara.

Overall Stelara Costs with Medicare:

While Medicare will cover Stelara, you'll still need to dig deeper into your pockets. Your invoice will include premiums, deductibles, and copayments. Monthly premiums differ due to private insurance companies providing Part D plans.

Deductible costs vary too, but they cannot exceed $590. After reaching this amount, you will pay 25% of your prescription drug costs; with Stelara, this percentage equates to between $2,590 to $7,500 on average for a single dose[3].

Once you've ponyed up $2,000, you enter the catastrophic coverage phase, meaning you won't need to pay anything for prescription drugs for the rest of the year.

Medicare Resources:

For additional insights navigating the convoluted world of medical insurance, head over to our bustling Medicare hub.

Deep Dive into the Costs:

1. Base Stelara Cost:
2. The wholesale acquisition cost (WAC) for a 90mg dose of Stelara is roughly $30,000[3].
3. Copays and Coinsurance:
4. Through Medicare Part D, Stelara's cost-sharing is usually lumped under Tier 5, classified as a specialty drug. Copayment, depending on your plan details, can run up to 33% of the drug's cost, around $9,900 for a single dose[5].
5. Catastrophic Coverage:
6. After hitting the $2,000 out-of-pocket threshold, patients qualify for zero additional costs for covered drugs, including Stelara[2].
7. Potential Discounts:
8. Some patients with commercial insurance may take advantage of the Stelara copay card, reducing their dose cost to $5. However, this often doesn't apply to those on Medicare[1].

Cost Comparison in Medicare Advantage Plans:

1. Tier 5 Costs and Fees:
2. The outlay can vary drastically among Medicare Advantage plans, as Stelara usually falls under Tier 5, as a specialty drug. You might still face similar 33% coinsurance costs, identical to Part D plans.
3. Illustrative Figures:
4. In certain Medicare Advantage plans like the Mass General Brigham Health Plan, patients may pay around $100 for a 30-day supply under specific conditions, with no extra costs post-catastrophic limit[5].
5. No-Deductible Plans:
6. Strategies like the BCN Advantage HMO feature no deductible, with fees varying by coverage stage and selected pharmacy. Initial out-of-pocket expenses make no small difference in determining your total costs, depending on your plan's specifics[2].

Out-of-Pocket Costs Summary:

• Initial Coverage: You may spend up to 33% of Stelara's cost with both Part D and Advantage plans.
• Catastrophic Phase: After surpassing $2,000 out-of-pocket expenses, Stelara and other covered drugs may become free.

Conclusion:

While costs associated with Stelara through Medicare Part D and Advantage plans can be substantial, the final outlay depends on the intricacies of your specific plan, including potential discounts and coverage phases. Make sure to scrutinize your Medicare plan details accurately to get a clear grasp of what you'll have to fork over.

1. Stelara, a medication for conditions such as psoriasis, is covered under Medicare Part D, which typically covers prescription drugs, making it a more suitable fit compared to Medicare Part B.
2. Medicare Advantage (Part C) plans may provide drug coverage (Part D) as part of a combined package, and they commonly cover prescriptions like Stelara.
3. While Medicare will cover Stelara, the costs you'll still need to pay include premiums, deductibles, and copayments, with the deductible costs varying but not exceeding $590 per year.
4. In the catastrophic coverage phase, which kicks in once you've spent $2,000 out-of-pocket, you won't need to pay anything for prescription drugs for the rest of the year, including Stelara.

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