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Insurance coverage

Sat, November 10, 2018 4:16 PM

I’m a prospective Entyvio user and would appreciate learning of others’ experiences with insurance authorization and coverage. I am on Medicare and in a position to enroll in either an MVP health care plan or an Empire Blue Cross plan.

250Alpine
Joined Nov 10, 2018

Mon, November 19, 2018 8:36 AM

Reply posted for kumputer.

Thank you for the reply and information. I appreciate the advice. Stay well.

Paula Haiko
Joined Nov 18, 2018

Sun, November 18, 2018 10:42 AM

Reply posted for 250Alpine.

I am on Medicare Part A and all the Advantage Plans I have found that cover my Humira would cost me over$21,000 out of pocket per year. How do Medicare patients afford Humira or Entyvio? Is your Blue Cross plan paying? I would like information, as I can't afford $21,000 a year. Thanks

Paula Haiko
Joined Nov 18, 2018

Mon, November 12, 2018 1:28 PM

Reply posted for 250Alpine.

I'm on Anthem Blue Cross, and I never had any issues with coverage, but I think more than anything it has to do with the medical practice's request for authorization and the reasons they provide. The most important financial resource to use while being treated with any of these expensive biologic treatments is sometimes called "copay assist".

The drug makers have a strong financial motivation to keep you on your meds, and they know that insurance usually does not cover 100%, so they pay the difference for you. This usually includes copays as well as any payment toward your insuarance decuctible and even toward your out-of-pocket maximum. In my case, a family decuctible of $3000 and an out-of-pocket maximum of $6000 means I would easily have to pay $6000 per year from my own wallet were it not for these financial assistance programs. Instead it's much closer to $0.

Some words of advice, though. Do your best to get your biologic treatments as early as possible after the new year. After only a single infusion, your decuctible as been more than paid for, and you're already almost up to your out-of-pocket max. I made the mistake this year of going to the ER early this year for something I might not have really needed treatment for, before I got my first insusion, and I'm still paying the bills for it. Get your infusions first if you can, and then your whole family is covered 100% for anything after.

kumputer
Joined Jul 19, 2013

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