Make sure you re covered for your biologic medicine!
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- Alicia Cummings
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1 It s open enrollment time Make sure you re covered for your biologic medicine! Joint Decisions is brought to you by Janssen Biotech, Inc., in partnership with CreakyJoints CreakyJoints Bringing arthritis to its knees since 1999
2 Is your health plan coverage changing in 2015 are you ready? The information in this brochure is provided so you can make the coverage decision that s right for you. Open enrollment is the time every year you can make changes to your health plan, or sign up for a new one. Even if you keep your same health plan, your benefits can change. Now is the time to make sure you have the insurance coverage you need so you can continue to get your biologic medicine in Your coverage and out-of-pocket costs can change from year to year. Your coverage and costs for your biologic medicine may be different next year. Here s what you need to do Make a list of all the medicines you and your family are taking. Check your plan options for next year. Make sure your doctors, medicines, and treatments are covered. See page 3 and contact your plan representative. Outline your Medical and Pharmacy benefits. Use page 5 if you have commercial or private insurance, or page 7 if you have Medicare coverage. Call your commercial or private insurance health plan representative or your local Medicare representative to get answers about coverage and costs for your biologic medicine. Open enrollment time is now make sure you re covered January 1, 2015 OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY Commercial or Private Insurance: Dates vary. Most plan decisions must be made by November 30. Medicare: Starts October 15 ends December 7th. Select or change a Medigap, Medicare Part D, or Medicare Advantage plan. Health Insurance Marketplace (HealthCare.gov)*: In many states, starts November 15 ends February 15. Check with your plan. * If you purchased your health plan through the Health Insurance Marketplace, you have Private Insurance. Call your plan to find out if you meet income requirements to qualify for help paying your premiums or out-of-pocket costs. See pages 4 and 5. 2
3 Coverage for your biologic medicine depends on how it is given If you have Commercial or Private Insurance Questions to consider Biologic medicines may be covered under your plan s Medical Benefit or the plan s Pharmacy Benefit, or both. Your costs can vary depending on how your treatment is given. See pages 4 and 5 for commercial or private insurance coverage information for your biologic medicine. If you have Medicare coverage Questions to consider Your costs may change next year. Visit Medicare.gov to find out more. See pages 6 and 7 for Medicare coverage information for your biologic medicine. See back cover for a helpful glossary of health insurance terms. Infusion or injection by a nurse at a doctor s office or infusion center Medical Benefit Does my plan include a deductible, co-pay, or co-insurance for each treatment? Is there a plan that covers my medicine costs and the cost to give me my infusion or injection? Does my plan have an individual or family out-ofpocket maximum? What happens after it is reached? Medicare Part B Do I have to pay a deductible and co-insurance before Medicare pays its share? Is a Medigap plan available to help cover my costs? Please note: Instead of Medicare Part B, a Medicare Advantage (Medicare Part C) plan may be available to help pay for your treatment costs. Some limitations may apply. You inject the medicine yourself at home, after training Pharmacy Benefit Do I have a co-pay for every prescription and refill? Does my plan have an annual limit on how much it will pay for my medicines? Medicare Part D What are my deductible and co-insurance costs? How much of my biologic medicine cost do I pay in the coverage gap or donut hole? How much do I have to pay after the donut hole? Instead of Medicare Part D, is a Medicare Advantage (Medicare Part C) plan available to help pay for my medicine costs? Make sure you re covered January 1, Check with your health plan to get the answers you need. Cost support may be available to help you save on the cost of your biologic medicine. 3
4 Commercial or Private Insurance Coverage for your biologic medicine Make sure you have the coverage you need in Medical Benefit Covers infused or injected biologic medicines given by a doctor or nurse Out-of-pocket maximum reached How does it work? May include an individual or family deductible May include co-pay or co-insurance: For biologic medicine cost For cost of infusion or injection May include an individual or family out-of-pocket maximum After out-of-pocket maximum is reached, your costs may be 0 Full Year Please note: Biologic medicine costs, and the costs to give you your infusion or injection may be covered up to 100%. Check your plan. If your plan includes a family out-of-pocket maximum and you reach it, you and your family may have no further medical costs for the year. Cost support may be available for your biologic medicine A cost support program may be available to help you save on the out-of-pocket cost for your biologic medicine. Independent foundations may be available to help you save on the cost of your biologic medicine. Pharmacy Benefit Covers biologic medicines you inject yourself For each prescription and refill, you pay a co-pay or co-insurance How does it work? Full Year Please note: There may be a limit on how much your prescription plan will pay in a year for your prescription medicines. Check your plan. Cost support may be available for your biologic medicine A cost support program may be available to help you save on the out-of-pocket cost for your biologic medicine. Independent foundations may be available to help you save on the cost of your biologic medicine. Use the next page to review your health plan coverage for your biologic medicine. See page 8 for a helpful glossary of health insurance terms. 4
5 Commercial or Private Insurance Coverage for your biologic medicine See what your treatment costs may be. Get the answers you need. Review your health plan materials or talk to your plan representative. Medical Benefit Covers biologic medicines given by infusion or injection by a nurse at a doctor s office or infusion center. Coverage includes 1. The cost of your biologic medicine 2. The cost to give you your infusion or injection 1. Coverage of costs for your biologic medicine Does your plan cover your biologic medicine? Yes* No Your co-pay Your co-insurance *You may qualify for a cost support program. 2. Coverage of costs to give you your infusion or injection Does your plan cover the cost of giving you your infusion or injection? Yes No Your co-pay for each infusion or injection Your co-insurance for each infusion or injection 3. Your deductible and out-of-pocket maximum Your deductible Does your deductible count toward your out-of-pocket maximum? Yes No Your annual out-of-pocket maximum, if any Please note: Your out-of-pocket costs count toward your family out-of-pocket maximum. These include the co-pay or co-insurance costs for your biologic medicine, as well as the cost to give you your infusion or injection. These costs may also count toward your deductible. If you reach your family out-of-pocket maximum, your family may have no further medical costs for the year. % % Pharmacy Benefit Covers prescription biologic medicines you inject yourself at home. Coverage of costs for your biologic medicine Does your plan cover your biologic medicine? Yes* No Your co-pay for each fill = x (number of injections per year) = Total out-of-pocket cost Does your plan have an annual limit on what it will pay for your prescriptions? Yes No Plan annual benefit limit *You may qualify for a cost support program. Total out-of-pocket costs (see example below) Please note: Your plan may have an annual benefit limit for your prescription medicines. In this case, you will need to consider this limit and how it affects the cost of your biologic medicine. Doing this will help you understand your potential out-of-pocket costs for your medicine. Example: Find out the total annual cost of your medicine(s) Subtract your plan annual benefit limit (if less) Equals medicine cost you are responsible for = Then add your annual co-pay costs + Your total annual out-of-pocket cost for your medicine(s) = If eligible, a cost support program may be available to help you save on the out-of-pocket costs for your biologic medicine. Cost support may be available to help you save on the cost of your biologic medicine. 5
6 Medicare Coverage for your biologic medicine Make sure you have the coverage you need in Medicare Part B Covers infused or injected biologic medicines given by a doctor or nurse How does it work? You pay annual deductible You pay 20% of medicine and infusion or injection costs Medicare Part B covers 80% of medicine and infusion or injection costs Supplemental coverage may be available Medigap plans that be available to help you save on your annual deductible and co-insurance costs. Your out-of-pocket costs may be as low as 0 with some Medigap plans. Cost support may be available for your biologic medicine Independent foundations may be available to help you save on the cost of your biologic medicine. Please note: Instead of Medicare Part B, a Medicare Advantage (Medicare Part C) plan may be available to help pay for your biologic medicine and infusion or injection costs. Some limitations may apply to biologic medicines. If you are enrolled in a Medicare Advantage (Medicare Part C) plan, you cannot enroll in a Medigap plan. Medicare Part D Covers biologic medicines you inject yourself How does it work? You pay annual deductible Before the donut hole In the donut hole After the donut hole On average, you pay 25% On average, Medicare pays 75% You pay 45% Part D Program pays 55%* You pay 5% Medicare pays 95% *Biologic medicine company pays 50%; Medicare pays 5%. Supplemental coverage may be available If you have limited income and resources, you may qualify for Medicare Extra Help Low Income Subsidy. Please note: Instead of Medicare Part D, a Medicare Advantage (Medicare Part C) plan may be available to help pay for your biologic medicine costs. Cost support may be available for your biologic medicine Independent foundations may be available to help you save on the cost of your biologic medicine. Use the next page to review your health plan coverage for your biologic medicine. See page 8 for a helpful glossary of health insurance terms. 6
7 Medicare Coverage for your biologic medicine See what your treatment costs may be. Get the answers you need. Visit Medicare.gov or call your local Medicare representative. Medicare Part B Covers biologic medicines given by infusion or injection by a nurse at a doctor s office or infusion center. Medicare Part D Covers prescription biologic medicines you inject yourself at home. Deductible for 2015* * Based on preliminary Medicare Part B plan information for % for treatment costs Cost for each treatment x (number of treatments per year) = Include costs for biologic medicine and costs to give you your infusion or injection. Total out-of-pocket costs Is a Medigap Plan available? Yes No Medigap plans may be available to help you save on your deductible and co-insurance costs. Your out-of-pocket costs may be as low as 0 with some Medigap plans. 147* Deductible for for biologic medicine costs: 25% of medicine costs between 320 and 2,960 25% of 2,640 = 45% of medicine cost in the donut hole between 2,960 and ~6,876 45% of ~3,916 = 5% of medicine cost after the donut hole 5% of medicine cost above ~6,876 = Based on Medicare Part D plan information for Based on the total annual cost of your medicines. Total out-of-pocket costs ~1,762? Is a Medicare Advantage Plan available? Yes No Medicare Advantage (Medicare Part C) plans may be available to help pay for your medicine costs. However, some limitations may apply to biologic medicines. Note: If you are enrolled in a Medicare Advantage (Medicare Part C) plan, you cannot enroll in a Medigap plan. Is a Medicare Advantage Plan available? Yes No Medicare Advantage (Medicare Part C) plans may be available to help pay for your medicine costs. However, some limitations may apply to biologic medicines. Foundation support may be available. Foundation support may be available. Visit Medicare.gov or call your local Medicare representative to get the answers you need. Cost support may be available to help you save on the cost of your biologic medicine. 7
8 It s open enrollment time. Even if you keep the same health plan, your benefits can change. Make sure you have the coverage you need beginning January 1, Glossary General terms Co-pay: A set dollar amount you pay for medicines and healthcare services. : Amount you pay after you have met your deductible. Usually a percentage of the amount your health plan will pay. Deductible: What you must pay before your insurance begins to pay. Out-of-pocket maximum: The total maximum dollar amount you may pay for your medicines and healthcare services during one year. Secondary insurance plan: Some people have more than one health insurance plan. In this case, the secondary plan is the one that provides payment on claims after the primary plan pays. Health Insurance Marketplace or Exchange : The health insurance marketplace helps people who don t have insurance find a health plan that meets their needs and fits their budgets. Many people using the Marketplace will qualify for help with costs. If you buy a plan through the Marketplace, you have private insurance. Glossary Medicare-specific terms Supplemental coverage or Medigap : Private health insurance that can help pay some of the costs ( gaps ) that Medicare does not cover. It is called Supplemental because it adds to or supplements your Medicare benefits. Medicare Advantage (Medicare Part C): A Medicare health plan offered by a private healthcare insurance company. These companies have contracts with Medicare to provide Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Most of these plans also offer prescription medicine coverage. Donut hole or coverage gap: A temporary limit on what a Medicare Part D Prescription plan will cover. This coverage gap begins after you have spent a set amount. It ends when you reach a set (higher) amount. Medicare Extra Help Low Income Subsidy: A Medicare program to help people with limited income and resources pay for prescription drug plan costs, including deductibles and out-of-pocket expenses. Make sure you re covered January 1, Check with your health plan to get the answers you need. Cost support may be available to help you save on the cost of your biologic medicine. Joint Decisions is brought to you by Janssen Biotech, Inc., in partnership with CreakyJoints CreakyJoints Bringing arthritis to its knees since Janssen Biotech, Inc /
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