Medicare & Avonex question?

[rockstressminerals]

So, does anyone know what the co-pay on medicare is for Avonex?
I am on my husbands insurance and we are able to get the 10.00 co-pay. If I get on disability, I will no longer be able to get on the 10.00 monthy program. Does anyone know the co-pay for avonex on medicare?

[kryptonite]

Co-pay

I just started Avonex...3rd injection. I was told that my co-pay would be around $1,600 but you can call 1-800-456-2255 to speak with an ActiveSource coordinator about financial assistance. I don't pay anything for my Avonex, just had to send in a copy of my last year's income tax.

[dm0329]

Since Medicare Rx Programs have a "doughnut hole" I would "shop" for the best supplement available in your area. As a single PwMS, I qualified for the LIS (low-income subsidy) for assistance with my medication co-pays.

But, as a married PwMS, your income and assets, may not be eligible for the LIS. I have found that Medicare is quite upfront about what payments for which you are responsible. Each month, I get a print out from my Medicare Supplement showing my drug benefits (what they pay and what I am responsible for or what the LIS pays, etc.). At the end of the year, I frequently read the out-of-pocket cost is about !8,000 a year! But, as I said, everything is income & asset based.

Also, shopping for your Medicare supplement will provide important information. For example, I needed a Medicare supplement WITH a RX PLAN, etc. Reach out to plans available in your area. A headache but worth the time.

Best of luck mapping the Medicare maze!

[onlyairfare]

I think you have to be on disability for two years before you become Medicare-eligible, though your situation might be different, so check, don't just take my word for it!

That said, if you have other insurance available to you, like being covered under your husband's policy, that insurer may required to be the first payer ("primary") with Medicare being "secondary." So you might still be eligible for the $10 co-pay.

I do not take Avonex so I know nothing about their program. However, I take Gilenya and I was automatically put in their co-pay assistance program, which according to the paperwork covers up to $800 per month co-pay. I have reasonably good private insurance through my and my husband's employment, and if needed, I could afford the $80 per month co-pay my insurance requires for one of my other "non-preferred" medications. But apparently the Novartis program for Gilenya is not income/needs based.

When I was on Copaxone, my insurer at that time had a 25% co-pay requirement for a "Tier 4" drug, which would have been $800 per month. I could not afford that (on top of the $1,600 per month COBRA premium + $6,000 high-deductible + other co-pays) so I quit taking Copaxone, or any other DMD until 4 months ago.

I have a new neurologist now, affiliated with a medical school, and he participates in a number of MS drug trials. He told me to let him know if financial obstacles were going to prevent me from getting a DMD he prescribed. He said "That won't happen to you again." Maybe some of the neuros doing research have an inside track.

For people with Medicare coverage questions, I recommend calling 1-800-MEDICARE to ask them, and also talking with your pharmacist(s) and if you have access to the hospital social worker, or your husband's HR/health benefits specialist at his work, ask them too.

I never believe anything until I have heard the same thing at least 3 times. Best to get it in writing too!

I think it is a shame that for us MSers dealing with the insurance issues is nearly as bad sometimes as having the disease.

[SharonL]

Medicare Requires Injections at Doctor Office

You are eligible for Medicare 2 years after the date used for date of onset of disability on the social security disability application. For instance, it took 2 years for my application to be approved, but I immediately received Medicare as well as a large check for 2 years of disability income.

Once you are eligible for Medicare you have a small window of time to get a Medicare supplement. They can be EXPENSIVE, up to $500 a month. I pay $140 a month but they are no longer writing new policies. It may be that you can use your husband's policy as secondary and may not need anything else. Given the fact you have MS, you must get a secondary insurance or you will be responsible for 20% of the Medicare approved amount for everything from your primary care doctor visits, to blood test to MRIs.

Medicare covers Avonex provided you receive the injection at a doctor's office. If you have a supplemental policy, then you will pay the $150 deductible at the beginning of the year. Afterwards, everything will be free to you. Without the supplemental insurance the approved Medicare charge is about $1,200 PER WEEK! You would be responsible for 20% of that amount. Avonex is the only MS drug covered under Medicare. Everything else goes through Medicarepart D prescription coverage.

Hope this helps as I know it can be confusing.

A terrific resource is Biogen, inc. Just call the number listed for Avonex and they will pave the way for you. They can also tell you about any programs they have to help pay. They will also make arrangements with the doctor's office for the injections. They want you to take their medicine ($$$$$) so let them do the work for you!
I wish you the best!

** Moderator's note - Post broken into paragraphs for easier reading. Many people with MS have visual difficulties that prevent them from reading large blocks of print. **

[mmilkes]

much appreciated

Thank you for sharing your experience, the information is so appreciated.