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Insurance coverage for anti-rejection drugs

I've got all the forms to fill out to start the ball rolling on a kidney transplant.  I feel like I'm filling out a mortgage application as a first-time buyer of a new home.  Just the amount of information that is needed seems to be a bit overwhelming, but .... understandable.  One of the things I was concerned with was the fact that it is my understanding (correct me if it's the exception rather than the rule) that, once the kidney transplant is completed, I will need to take anti-rejection drugs for the rest of my life.  The main reason for that is because my body will "see" my new kidney as a foreign body and will try to attack it.  IF anti-rejection drugs is a "fact of life", literally and figuratively, does anyone have insurance to cover that?  If so, how much does it cover?  I have Medicare Parts A and B and I have Part D drug coverage on a plan known as SilverScript which is operated through CVS/Caremark.  It may seem I am looking at the end of a process, but the end DOES justify the means and will determine if this is truly something I want to get into.  Thanks for any info you can share.

Dave

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  • Hi Dave

    By now you get the idea that Rx are for ever. The only thing I could add to this is I’ve priced paying Rx (generics) via Healthwarehouse dot com and it works out to < 2500 annually. A big number but manageable if you found the right doctor insurance.

    I’m pricing out ACA and am seriously considering using my 36 mo of Medicare and buying an individual policy for my wife. Insurance is tough so do pay attention to details.

    I’m on Mycophenolate Moefeilil 250*4 / Tacrolimus 1 & .5mg / Pred 5mg / Carvedilol 12.5 / Sulfamethoalate Thi 400-80. All generics.

    In Cleveland diff health systems are covered by propirtary insurance. Bad deals.

    Good Luck. Still dealing with this is better than being tied to a machine a few times a week!
  • Dave, I've had my kidney for 15 years now and am very thankful but have been through it all insurance wise. I got my kidney while still working yet I was also covered by Medicare Part A and B through the automatic qualification with ESRD. I first was thrown off my insurance after the transplant with them saying I reached my lifetime max payments when they paid 85k for the donated transplant instead of the 7k a month they were paying for dialysis. I then thank goodness got my drugs through my wife's insurance until one day she came to work at 52 and was told the company was sold and the new one didn't want any of the employees. I then had to scramble back on Medicare part B and buy a Part D plan while I was still less than Medicare retirement age. Humana was my Part D plan and did a pretty good job of covering the meds until I reached my 66th birthday when they took my premium for the year and then denied coverage of my meds on my birthday leaving me to scramble to get them approved by and covered by Part B. Now coverage by Part B if retirement age is no problem it does leave you with getting your drugs once a month now instead of being allowed a 3 month supply (I guess Medicare's affraid you might die with a drug supply on hand). There will be a co-pay every month after your deductible is met for the year which isn't hard with a visit to your doctor once and that co-pay is minimal, in my case about 15 a month and not worth the cost of me taking a Medicare supplement plan and paying that premium every month. My point being that what you will find yourself into post transplant is being a mathematician and reading fine print in insurance plans to keep yourself from being raped by the insurance companies for little to no coverage. I at this point am much cheaper off to keep a useless Part D policy in force with a cheap premium that has a rediculuis deductible up front to keep from getting penalized for Part D later if needed while I get my doctor to cooperate with all the generics he can prescribe an my Part B coverage of my transplant meds. I use WalMart's 4 and 10 drugs a lot and get my transplant meds filled by them too. I find it cheaper in the long run to pay for most of my drugs without involving Part D insurance and save money while keeping the Part D option open should problems arise in the future when I can then choose a Part D plan that is worth something for my money. The transplant is the easy part, the cost dodge of insurance coverage afterwards is the challenge. Best of luck with your transplant, it's the best thing that ever happened in my life after my wife and kids and I'm forever grateful.
  • My meds are covered through my employers insurance plan.  For that I am very grateful.  Very.  Our coverage is very good.  But Aetna.  They are the worst.   Just be glad you're not on Aetna.  They make everything, and I meah EVERYTHING, as hard as possible to do.  They don't have your best interest at heart.  Not even close.  

    OK, maybe I exagerate.  But not much!

    The meds will be with forever unless they come up with something else.  

  • Hey Dave ,  Your advantage here is  .... your on medicare ...  with that said  medicare will cover your rejection meds 100%  ...   ... yes you will take rejection meds for the rest of your life ..  yes  rejection meds fool your body  into thinking the txplnt  organ  is suppose to be there

      hope this helps

  • Be mindful everyone, ordering by mail/email represents a cost savings of 30 % or more. Most plans offer this discount to encourage patients to use the service and will allow a 90 day supply.  Worth looking into if you medication doses are  stable.  Ordering once a quarter is so much less stressful, as well!

  • Hello Dave,

    I had my kidney transplant in July of 2005 and now after twelve years my kidney is in rejection, exceeding the ten year life-expectancy of a cadaver kidney by two years.  Along the way there were set-backs but with great physicians and medications I survived.  As far as my anti-rejections drugs I've been faithfully taking them as instructed every day since day one, and yes they are expensive but usually covered by my insurance Humana Part D with a co-pay.  Because my kidney is in rejection I am taking Mycophenolic Acid (generic for Myfortic) and the cost out-of-pocket can range anywhere from $440 to $185 for a 30 day supply depending where you are at in your twelve month plan (it gets expensive when you are in the "doughnut hole" and meeting your annual deductible.)  That's why it is so important to select the best insurance that will work for you as a transplant patient.  And remember, if you cannot afford your anti-rejection meds there is assistance out there.  The bottom line Dave is that you will be taking anti-rejection meds every day (and I mean EVERY DAY for the rest of your life.  As for me it's well worth the expense to wake up in the morning and be able to see my wife, children and grandchildren and enjoy my life to the fullest.  By the way, I'm going on 76 and looking forward to twenty more.

    God Bless

  • My husband was 67 at the time of transplant.   He had Medicare Part A  but was covered under my employer insurance.  In June, when I retired, we both went on Medicare and everything changed.  Previously his meds were covered under my prescription drug plan, but once I retired and he went on Medicare Part B, his immunosuppressants are covered under Part B.  He also has  a supplement plan, so he ends up paying nothing for the meds. He also has Part D drug coverage but they declined to cover the immunosuppressants because Part B covers them.  I think it has everything to do with whether you qualified for Medicare by virtue of your age (65+) at the time of transplant or whether you qualified under the ESRD exception.  You need to call Medicare and ask whether you will be covered under Part B or Part D.  The co-pay under Part B would be huge without the supplemental coverage.  And your Silver script will not help you if they determine it's Part B.  The people at Medicare are really nice and helpful!

  • As a Tx recipient on Medicare your immunosuppressant hedications will be covered for three years post surgery.  Other medications (BP, insulins, ... will be billed to your Part D carrier.  These benefits vary patient to patient so seek the help of your Tx social worker to explain further.

    • I believe the 3-year rule is for people who would not otherwise qualify for Medicare (due to age).  The poster is on Medicare already, so part B should cover the cost of drugs forever.

      • You are correct, I was placed on Medicare while on dialysis.  There are specific rules for ESRD beyond other Txs, Medicare & ESRD

        We'll see what this new congress does to Medicare.....stay tuned

        Signing up for Medicare if you have ESRD | Medicare.gov
        Learn how to sign up for Medicare if you have End-Stage Renal Disease (ESRD). If you're eligible for Medicare because of ESRD, you can enroll in Part…
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