Can A Clinical Trial Prescription Drug Avoid the Donut Hole?

Published 12:00 am Saturday, March 5, 2022

Toni:
I turn 65 in May and am covered by my wife’s employer group health insurance. I am fighting stage 3 kidney cancer and the prognosis is good since I am participating in a clinical trial for a new cancer medication which costs over $20,000 per month. With this clinical trial, I am paying $0 for a medication which is curing my cancer.
I am not planning to enroll in Medicare until my wife retires when she turns 65 in 2 years. I am concerned about Medicare’s famous donut hole and if this new prescription called Sutent is covered by Medicare’s Part D prescription drug plan. How long will it take me to get into the donut hole or will I even get in it?
Please explain Medicare and clinical trials and what I should do? Thanks, Matthew

Matthew:
You are incredibly wise to remain on your wife’s employer benefits because you both can enroll in Medicare Parts A and B when your wife retires in 2 years when she turns 65. At that time, you will be eligible for a SEP (Special Enrollment Period) avoiding the Medicare Part B penalty and be able to enroll in a Medicare Part D prescription drug plan.
Let’s discuss your expensive clinical trial prescription and if you will go in the “famous Donut Hole.” Prescriptions are the most important option discussed when a Toni Says® Medicare consultation is performed.
Yes, Matthew…you go in the “Donut Hole” the very second you order the prescription Sutent. For that reason, the Toni Says® Medicare team will search the Medicare.gov Part D prescription drug website for which Medicare Part D plan will best meet your Medicare and financial needs. Always enroll in the Medicare Part D plan which covers all your prescriptions even though the most expensive prescription is covered by a clinical trial program and costs you $0. There may be a time when that expensive prescription is no longer covered by the clinical trial, and you will have the expensive “Donut Hole” experience.
Your Medicare Part D prescription drug monthly cost is outrageous for the cancer medication Sutent. This is a tier 5 specialty drug and for the first month your copay is $5612 with you going in and out of the Donut Hole and into Catastrophic coverage immediately with $1,122.41 cost the second month to the end of the year. If one is not enrolled in a Part D plan that covers the expensive prescription, then you will pay 100% for any expensive prescription out of your pocket.
Enrolling in Medicare Part B for the first time when your wife retires is a good option. Both you and your wife will qualify for the Medigap/Medicare Supplement 6-month open enrollment period to start the month your Medicare Part B begins without having to answer health questions.
Original Medicare and your Medicare Supplement will work together with your clinical trial program to cover your medical needs. Original Medicare covers the routine costs of qualifying clinical trials. Your Medicare Supplement plans will pay the out of pocket that Original Medicare does not pay that meets Medicare qualifications.
When one chooses a Medicare Advantage plan with a clinical trial for a health issue, the Medicare Advantage plans is required to reimburse beneficiaries for the difference in out-of-pocket cost sharing between Fee for Service and their Medicare Advantage plan.
Matthew, take your time and search which Medicare option meets your needs. Email info@tonisays.com or call 832/519-8664 for Medicare help.
March’s Confused about Medicare Workshop in Katy is “Live” Thursday, March 31st at 6:00PM-8:00PM at Spring Creek BBQ-Katy 21000 Katy Frwy, Katy, TX 77449. Workshop is free with seating limited and dinner not included. Please RSVP 832/519-8664 or visit www.tonisays.com.