Pulmonary Fibrosis NOW! hopes that this information helps to ensure a smoother enrollment process for you and your loved ones. Remember, you are your biggest advocate so make sure to do your research, ask questions, and choose a plan that covers all your individual anticipated pulmonary fibrosis healthcare needs. Together, we can #fightPFNOW!
1) Prescription Costs: What prescription costs are covered by Medicare plans?
Medicare Advantage plans and Medicare Part D cover both, pirfenidone and nintedanib.
- There is a big price difference between the two major drugs prescribed for IPF. The monthly retail cost of 100mg Nintedanib (brand name Ofev) is approximately $5,033 (annually $60,396) and 267mg Pirfenidone (brand name Esbriet) is $1,051 (annually $12,612).
- The estimated yearly cost for patients on Original Medicare (not including the monthly plan premium) for Ofev would be approximately $4550 and for Pirfenidone would be approximately $1300. These rates are typically lower on Medicare Advantage plans.
- What you pay out of pocket for these medications varies depending on your healthcare plan and your state & county of residence, so be sure to check rates applicable to you and your plan; drug costs in the Original Medicare plan can be somewhat higher than that in Medicare HMO plans.
- Some medicare plans have restrictions on coverage of these drugs that may include:
- Quantity Limits: restriction on the amount of this prescription that can be purchased at one time.
- Prior Authorization. require you to obtain their authorization before they will provide coverage for this prescription.
- Nebulizers and albuterol pumps are also covered, but you have to pay 20% of the cost unless you have Medigap insurance.
2) Pulmonary Rehabilitation Costs: Is it covered by Medicare plans?
Short answer: Yes.
If you have PF or COPD, you may want to choose a plan that pays for pulmonary rehabilitation.
Medicare Part B and Medicare Advantage plans will cover most of the costs for pulmonary rehabilitation as long as you have a doctor referral and meet certain minimum requirements. However, please check if your plan will pay for this particular service. Your doctor or other health care provider may recommend you get this service more often than Medicare covers. If that happens, you may have to pay some or all of the costs.
For more information on pulmonary rehabilitation, click here.
3) Supplemental Oxygen Costs: Does Medicare cover Supplemental Oxygen costs?
Short Answer: Yes.
If you have PF or COPD, you may want to choose a plan that pays for supplemental oxygen.
Medicare will help pay for oxygen equipment, contents and supplies for the delivery of oxygen when all of these conditions are met:
- Your doctor says you have a severe lung disease or you’re not getting enough oxygen
- Your health might improve with oxygen therapy
- Your arterial blood gas level falls within a certain range
- Other alternative measures have failed
If you meet the conditions above, Medicare oxygen equipment coverage includes:
- Systems that provide oxygen
- Containers that store oxygen
- Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents
- Humidifier when it’s used with your oxygen machine
Your costs in Original Medicare:
You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you have Medicare and use oxygen, you’ll rent oxygen equipment from a supplier for 36 months. After 36 months, your supplier must continue to provide oxygen equipment and related supplies for an additional 24 months. Your supplier must provide equipment and supplies for up to a total of 5 years, as long as you have a medical need for oxygen.
The monthly rental payments also cover oxygen accessories and services like tubing or a mouthpiece, oxygen contents, and oxygen machine maintenance, servicing and repairs.
What happens after I rent my equipment for 36 months?
For more information on oxygen equipment coverage, click here.
Please contact your local SHIP (State Health Insurance Assistance Programs) organization https://www.shiptacenter.org/ ; 1-877-839-2675 to get customized cost for your specific coverage needs. They can provide one-on-one assistance with reviewing health or prescription drug plan options that are right for you.