Can A Clinical Trial Prescription Drug Avoid the Donut Hole?
Toni:
I turn 65 in May and am covered by my wife’s employer group health insurance. I’m 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 prescription drug plan and Medicare’s donut hole. Please explain Medicare and clinical trials and what I should do? Thanks, Matthew, Dallas, TX
Matthew:
You are 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 would go in the “famous Donut Hole” with a Part D plan. Prescriptions are the most important option discussed during a Toni Says® Medicare consultation.
Matthew, you would go into the “Donut Hole” the very second you order an expensive prescription such as the one you are taking that would cost over $20,000 per month if you were not in a clinical trial. The Toni Says® Medicare team will search the Medicare.gov Part D prescription drug website for the Medicare Part D plan that 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.
Cancer brand name prescriptions are usually a tier 5 specialty drug with the Medicare Part D prescription drug plan cost going in and out of the “famous” Donut Hole and into Medicare Part D’s Catastrophic coverage immediately.
If one is not enrolled in a Part D plan that covers the expensive prescriptions, then you will pay 100% out of your pocket for the expensive prescriptions that are not covered.
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 during your 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.
For those enrolled in a Medicare Advantage plan seeking clinical trials, the 2023 Medicare and You handbook under Clinical Research Studies states that “if you’re in a Medicare Advantage plan Original Medicare may cover some costs along with your Medicare Advantage plans”. Please discuss your clinical trials options with the Medicare Advantage plan you are enrolled in and the doctor/facility providing the care.
Matthew, take your time and search which Medicare option meets your needs. Email info@tonisays.com with Medicare questions or call 832/519-8664 for a Medicare consultation.
Visit www.seniorresource.com/medicare-moments to listen to Toni’s Medicare Moments podcasts and to also download the Toni Says® Medicare Prescription Drug Survival Guide. Toni’s book “Medicare Survival Guide Advanced” edition available at www.tonisays.com.
