Getting Tremfya paid for? Haven't made any Medicare/Medigap/Advantage choices yet.

InTheWoods

InTheWoods

New Member
Location
Maryland
I'm asking for my spouse. She gets Tremfya (an injectable) for psoriasis, it works well, and she hasn't gotten much relief from any alternatives so far. My employer's plan has been paying for it. I want to retire now. But what research I've done so far suggests it's nearly impossible getting it paid for with Medicare plus insurance we can buy. It supposedly costs over $142,000 per year without insurance. That's eighteen million dollars a quart!! The maker has a savings plan but our income will be a little over their household limit to use their savings plan.
We could choose her Medicare and insurance plans to cover the drug, but I'm not making much headway figuring out whether any options will work. Her doctor suggests we should go ahead and choose any plan, and then they'll work to see if the plan will cover it. The doctor says we can ask plans if they will cover it but they often won't give a straight answer. They say some of their patients get it covered, but they aren't allowed to tell us anything about how.
This seems backwards! Once she is committed to a plan, she has no power left about this issue.
On forums specifically about that drug, many say they lose access to it when somebody retires. A mainstream solution is to find some substitute that has to be injected slowly over a couple hours, which is done in an infusion center and therefore counts as a medical procedure covered under Medicare B. Of course we don't know if any substitute will work, but, then, we don't know if Tremfya injections would keep working, either.

Anybody have any tips about how to do this?

Thank you!
 

I don't have any tips, but it is shocking what they charge for it, especially since their advertisements say $5 a dose (unless I'm thinking of a different drug advertisement).

I used the drug plan tool and it did say $142,000+ per year via mail order for all the prescription plans ('only' $111,000+ using pharmacies). I'm not sure whether that was assuming monthly or every two months injections.

So basically it is not covered as a prescription. The Tremfya website gave the medical code that doctors should use and said they can assist with getting pre-authorization, so that sounds like it could be covered under medicare supplement plans as medical treatment, but I guess you'd have to talk to each plan, and like you said, they might not be guaranteeing anything.

I tried searching Canadian pharmacies and that made it sound like $4,000 a shot. Assuming bi-monthly (6 per year) guess it could be a mere :rolleyes: $24,000 (if you can go pick it up in Canada? Website I looked at sounded like only ship to Canadian addresses.).

Hope you find someone who is having success getting it covered. I was started on an expensive ($3,500 twice a year) osteoporosis injection by a doctor who knew how to procure it as a medical procedure, then I moved and the new doctor's office kept telling me they needed my plan D info for it even though I kept telling them it is only covered as a medical procedure not through prescription. That doctor changed me to the cheaper osteoporosis pill medications. I guess if I ever want to use the injectable med I would need to find a way to educate them on how to do their jobs. Ugh.
 
I also got funding from this foundation. The Healthwell Foundation.
https://www.healthwellfoundation.org/

Both of these foundations have separate funds for a variety of diseases and treatments. I was assigned a case worker who took my insurance info and figured out for me what my annual out of pocket would be. Then they put that into an account for me and all I had to do was get my clinic/ hospital to bill them after my insurance had paid their portion. Good luck to you! I need to add...I found these foundations by calling the drug company that made my med and asking for their help. They got the foundation staff on the line and introduced me. Once the foundation said they would help me the drug company person hung up.
 
Last edited:
Go to their website and look across the top, click on cost support and more. Call and ask them any questions , some drug companies will assist you through their patient assistant prograns regardless if you are on medicare part D are not. Usually it depends on income or your co pay on part D.You would be surprised at the income levels some let you have to qualify. I was actually shocked when looking for a friend for a drug that was needed.I hope you find the needed info you need.
 
perplexed said:
Go to their website and look across the top, click on cost support and more. Call and ask them any questions
Click to expand...
Thanks. I've done that, explored their website and links, called them, called several other organizations they told me about. Nothing. Our income is not way above the household maxes, only a few percent in some cases.

A number of references and people I talked to told me that the way to do this is pick any insurance program and buy it, and then start the process of trying to get them to pay for it. Which still seems backwards.

Several places told me the right way to do this is through the "Biologics Coordinator", which is a role in a typical dermatology practice. So I scheduled a phone meeting with ours, and she said she wasn't allowed to provide any guidance on plans that cover Tremfya, that I could try calling plan companies before buying but they would probably not give a straight answer (only something like "we'll see"), and that we should probably choose a plan and buy it and then start the process, which at that point would also involve the doctor himself.

Tremfya costs over $18,000 per dose, which is given every 8 weeks. By the way, that means their liquid costs over eighteen million dollars per quart. Treatment is $142,000 per year. I've read reassuring references that say, don't worry, when you get over $7400 (I think that was the number), Medicare catastrophic coverage kicks in to limit your out of pocket, covering all but 5%. However, the very first dose of the year would be way more than the catastrophic limit, and then that 5% we'd have to pay would still be over $7000 additional, so this one med for her would cost us over $14,000 per year. And I still have to pay for my own medical care. It's hard to believe we are talking real money here; I think there has to be some imaginary economy at work; I don't think the coverage she has been receiving so far happened because insurance companies habitually let dermatologists make $142,000/year commitments for them.

And yet, our Biologics Coordinator seemed to be implying that it would all work out OK, or at worst they could find some other med that would take care of her. And, of course, there's no guarantee the Tremfya would have kept working, or that something better isn't soon to be announced. So I think we're going with the Biologics Coordinator's advice (which prevails in other references too) and just picking any plan on its general merits, and hoping for the best.

It's weird. And I'm a little afraid I'm going to find more of this kind of issue in the future.

Thank you everybody!
 
So your income IS above the limit?? They are sticklers on income limits, I am sorry, there has to be another way to get that drug the cost is so high. Who can afford that ?? I guess there is no generic yet either, have you tried good RX to try and lower costs even a little?
 
well that is 5000.00 lower on Good rx compared to 18,000 but still that is outrageous! You might try calling the company back and asking for a supervisor and explaining your situation.I go over peoples heads a lot and many times it works and other times not. You just never know until you try.I sure hope you find a solution.
 
InTheWoods said:
I'm asking for my spouse. She gets Tremfya (an injectable) for psoriasis, it works well, and she hasn't gotten much relief from any alternatives so far. My employer's plan has been paying for it. I want to retire now. But what research I've done so far suggests it's nearly impossible getting it paid for with Medicare plus insurance we can buy. It supposedly costs over $142,000 per year without insurance. That's eighteen million dollars a quart!! The maker has a savings plan but our income will be a little over their household limit to use their savings plan.
We could choose her Medicare and insurance plans to cover the drug, but I'm not making much headway figuring out whether any options will work. Her doctor suggests we should go ahead and choose any plan, and then they'll work to see if the plan will cover it. The doctor says we can ask plans if they will cover it but they often won't give a straight answer. They say some of their patients get it covered, but they aren't allowed to tell us anything about how.
This seems backwards! Once she is committed to a plan, she has no power left about this issue.
On forums specifically about that drug, many say they lose access to it when somebody retires. A mainstream solution is to find some substitute that has to be injected slowly over a couple hours, which is done in an infusion center and therefore counts as a medical procedure covered under Medicare B. Of course we don't know if any substitute will work, but, then, we don't know if Tremfya injections would keep working, either.

Anybody have any tips about how to do this?

Thank you!
Click to expand...
Look and see if there is an insurance broker in your area. I just retired and have some medical needs. Didn’t cost us anything, I had to give her my current diagnoses and prescription meds and go from there. Yes I have a new 5,000 deductible that I’m responsible for, my job used to pay half of it prior. But I’m glad I went this root. I have 2 prescriptions that are very high, not as high as your wife’s but between GoodRx till I meet my deductible I’m in good shape till I’m old enough for Medicare and a supp. Hope this helps a tad.
 


Back
Top