With Open Enrollment starting on October 15, two AnCan’rs asked for advice this week on Medicare plans – and yes it’s complicated. AnCan recommends you watch the webinar we held last October to help understand the difference between traditional Medicare and Medicare Advantage. The dollar details are different for 2025 but not the principles.
Lastly, my own health insurance broker, Kim Umphres, is licensed to write in 15 States. He offered his help to all in last year’s webinar, so take him up umphres100@yahoo.com
Since the same questions are likely in the mind of many others, I have written this Blog Post. I am no expert but this may illustrate how I think about my own health insurance. Sadly, I cannot help you all individually – consult with your own Medicare health insurance for the best advice.
Onward & upwards, rick
Many of us on Medicare are faced with renewing our plans – or buying a plan for the first time. If you choose not to buy a plan to supplement Medicare, it leaves you exposed to roughly 20% of your medical costs. That can amount to very big bucks!
The main choice is whether to opt for Traditional Medicare + a Supplement (Medigap) Plan + a Drug Plan. Alternatively, a Medicare Advantage Plan can look attractive but comes with warts.
If you are low income and cannot afford the available plans, there are Medicaid alternatives for Medicare supplements.
Advantage Plans (Plan C) restrict your choice of Health Care Providers since they are based on Provider Networks. If you need a particular type of specialist, for example a genitourinary medical oncologist, or a neurologist who specializes in MS, this can be a problem with Advantage. Community Standard of Care is often the byword. If you choose an Advantage Plan, be sure it covers HCPs who practice at a Center of Excellence.
Advantage Plans usually have small monthly premiums, sometimes zero. They also include co-pays when you visit a Provider. Co-pays can be anywhere from Zero dollars to several hundred for fancy scans like PSMA, so you have to look carefully at the coverage. The more you use the plan, the more you pay. Some may include coinsurance – avoid those altogether. It’s a nuance we won’t get into here.
You can also go out of network to a Provider of your choice, but copays will be significantly higher. For example, you may pay $50 for a visit to a specialist in-network. Out-of-network, the cost can be significantly higher – often 40% of the approved Medicare fee for the service sought.
Advantage Plans often have a Gatekeeper who must approve any referral. You may not be able to self refer. Also there can be stricter intervention by the Plan to pre-approve procedures.
Drugs are included, however there is also a co-pay for some generic and all branded drugs that depends on the tier in which they are classified in the Plan’s drug formulary. List the drugs you use and find the cost. That said, the good news in 2025 is that drug out-of-pocket costs cannot exceed $2,000.
Traditional Medicare with a Supplement (Plans F,G,K,L,M,N) may not restrict your choice of HCPs – you can go anywhere in or out of state provided the Provider accepts Medicare.
Traditional Medicare Supplement Plans cover the 20% not covered by Medicare A and B. You pay a monthly premium that varies according to the plan chosen. The different supplement plans have different features. The more you pay in monthly premium, the less the restrictions and the lower the deductibles.
In addition you will need drug coverage (Plan D). Again that includes a monthly premium, plus a charge for each drug, so you have to shop plans against your Rx. For 2025, drug out-of-pocket costs cannot exceed $2,000.
As long as your chosen Provider accepts self-referrals, there may be no Gatekeeper. Procedures and protocols may still be subject to pre-approval.
Since Advantage Plans can be more profitable for the Payer, they offer lots of bells and whistles to sell the plan – for example subsidies for OTC products. One plan I was offered recently, actually pays the Holder $5/month!
I’m trained as an economist so I look at risk reward. I compare the annual maximum out-of-pocket cost between the Advantage Plan and the Traditional Medicare Plans (inc. the drug plan).
For traditional Medicare There is a required monthly premium for both the Supplement and the Drug Plan. Add those together and multiply by 12. In addition you can have out-of-pocket drug costs, especially if you are using expensive cancer drugs, but that cannot exceed $2,000 in 2025. Btw, the $2000 will decrease in subsequent years.
Each Advantage Plan has a stipulated maximum out-of-pocket cost for in-network and out-of-network Providers. In-network will be less. I look at the out-of-network max, and add to that any monthly premiums that are usually minimal. Drugs are included with a co-pay, but that co-pay cannot exceed $2,000 in 2025.
Now that I know what I HAVE to pay with Traditional + Supplement vs what I could pay with Advantage depending on my usage, I can compare whether I want to roll the dice to save money.
If the Traditional route costs me $500 in monthly premiums, I know I am out-of-pocket $6,000 plus my drug copay costs capped at $2,000.
Say my Advantage Plan has a monthly premium of $25, then for sure I am out of pocket $300. The rest depends on how much medical care I use. Assume ( the economist’s favorite word) the out-of-pocket for out-of-network in my plan is $8,000, that is my max. I still have to consider up to $2,000 for drugs.
Let’s compare!
IN THE WORST CASE I am spending $6,000 (+ drugs) for Traditional Supplement versus $8,300 (+ drugs) for Advantage. The Advantage could be $2,300 more pricey.
IN THE BEST CASE, I am out-of-pocket $300 (+ drugs) for Advantage vs $6,000 (+ drugs) for Traditional Supplement, so I could save $5,700 with Advantage.
Risk-Reward… do I want to roll the dice to save up to $5,700 that could cost me an extra $2,300??
Each person has to make that decision.
There’s more to it than this. For example HMO’s like Kaiser Permanente may make it even harder to go out of network. And with KP, you are guarantied to only get community Standard of Care medicine . As I often say, KP is great as long as you don’t get seriously ill.
AnCan strongly suggests finding a local Medicare Health Insurance Agent to help you sort through this morass. Plans change by State, so your agent must be licensed in your State.
And one last thing. The first time you enter Medicare there is NO underwriting. No matter your preconditions, you are accepted to any Traditional supplement or Advantage Plan. In subsequent years, you may be subject to underwriting should you choose to switch plans. You can be restricted from changing between an Advantage and Traditional Supplement Plan.
AnCan recommends watching our webinar from last October to help understand the difference between traditional Medicare and Medicare Advantage. 2025 details are different but not the principles.
We also recommend you visit the Triage website and attend its free webinars. Many of their Medicare resources can be found at https://triagecancer.org/medicare-cancer
For differences between the Traditional Supplement Plans, consult with a specialized Medicare Health Insurance agent. F and G are the best options. There are also high deductible options. An agent can also help you compare Advantage plans by various criteria, like maximum out-of-pocket for out-of-network care.
Hi-Risk/Recurrent/Advanced PCa Video Chat, Oct 8, 2024
AnCan is grateful to the following sponsors for making this recording possible: Bayer, Foundation Medicine, Janssen, Myriad Genetics, Novartis, Telix & Blue Earth Diagnostics.
AnCan respectfully notes that it does not accept sponsored promotion. Any drugs, protocols or devices recommended in our discussions are based solely on anecdotal peer experience or clinical evidence.
AnCan cannot and does not provide medical advice. We encourage you to discuss anything you hear in our sessions with your own medical team.
AnCan reminds all Participants that Adverse Events experienced from prescribed drugs or protocols should be reported to the pharmaceutical manufacturer or the FDA Adverse Event Reporting System (FAERS). To do so call 1-800-332-1066 or download interactive FDA Form 3500 https://www.fda.gov/media/76299/download
AnCan’s Prostate Cancer Forum is back (https://ancan.org/forums). If you’d like to comment on anything you see in our Recordings or read in our Reminders, just sign up and go right ahead. You can also click on the Forum icon at the top right of the webpage.
All AnCan’s groups are free and drop-in … join us in person sometime!
Editor’s Pick: Don’t suffer in silence with joint pains after starting ADT (bn)
Topics Discussed
Only 6 months of Orgovyx with his salvage radiation — too short?; aching joints on ADT are incapacitating him; he struggled to get proton beam but standard radiation therapy is looking better and better; public service message: get your flu shot!; PSA creeping up despite hormone therapy — should his docs be doing more?; put questions for the doc in writing; is a broader field of coverage better for salvage therapy?; feeling better after radiation fatigue, and battling melanoma, too; suspicious lymph node, but it’s dangerously close to the rectum
Chat Log
? · 6:32 PM
All imaging was negative so how do fiduciary makers help?
Hi-Risk/Recurrent/Advanced PCa Video Chat, Sep 30, 2024
AnCan is grateful to the following sponsors for making this recording possible: Bayer, Foundation Medicine, Janssen, Myriad Genetics, Novartis, Telix & Blue Earth Diagnostics.
AnCan respectfully notes that it does not accept sponsored promotion. Any drugs, protocols or devices recommended in our discussions are based solely on anecdotal peer experience or clinical evidence.
AnCan cannot and does not provide medical advice. We encourage you to discuss anything you hear in our sessions with your own medical team.
AnCan reminds all Participants that Adverse Events experienced from prescribed drugs or protocols should be reported to the pharmaceutical manufacturer or the FDA Adverse Event Reporting System (FAERS). To do so call 1-800-332-1066 or download interactive FDA Form 3500 https://www.fda.gov/media/76299/download
AnCan’s Prostate Cancer Forum is back (https://ancan.org/forums). If you’d like to comment on anything you see in our Recordings or read in our Reminders, just sign up and go right ahead. You can also click on the Forum icon at the top right of the webpage.
All AnCan’s groups are free and drop-in … join us in person sometime!
Editor’s Pick:Do T3c men (seminal vesical invasion) need a 2nd line anti-androgen? (rd)
Topics Discussed
T3c Newbie more concerned about heart than remaining above the grass; KP Newbie struggles to get SoC; yet another young denovo Mx Newbie; 4 years out, denovo Mx Newbie is still with clueless uro; daro causes enormous fatigue and brain fog – maybe slight improvement on enz; GU med onc drops ARSI for T3c man and doesn’t replace it – should she? Dr, Larry Fong move to UDub; how do we keep the cancer unstable for men on long-term HT?
Chat Log
dennis carden
sent: 5:49 PM
ty!! definitely will! What time does it normally start?
Jim Marshall, Alexandria, VA
sent: 5:49 PM
Next Tuesday at 06:00pm ET. Jim
dennis carden
sent: 5:50 PM
ah excellent, ok! ty!!
Jim Marshall, Alexandria, VA
sent: 5:50 PM
1st & 3rd Mondays at 08:00pm ET, 2nd & 4th Tuesdays at 06:00pm ET.
dennis carden
sent: 5:51 PM
ah, will make a note of this, ty!!!
dennis carden
sent: 5:53 PM
no..and i’m 62 recently retired..so too early for medicare unfortunately..have aetna
John A
sent: 5:55 PM
Dr. Andrea Harzstark
John A
sent: 5:58 PM
Somatic mutations (as opposed to germline mutations)
Keith Lawrenz
sent: 6:06 PM
Zometa
Steve Roux, MI
sent: 6:18 PM
Love you guys but the Detroit Lions need my attention. LOL. Goodnight!
John A
sent: 6:25 PM
Regarding Len’s question…if necessary he could ditch RT in favor of chemo–??
Hi-Risk/Recurrent/Advanced PCa Video Chat, Sep 24, 2024
AnCan is grateful to the following sponsors for making this recording possible: Bayer, Foundation Medicine, Janssen, Myriad Genetics, Novartis, Telix & Blue Earth Diagnostics.
AnCan respectfully notes that it does not accept sponsored promotion. Any drugs, protocols or devices recommended in our discussions are based solely on anecdotal peer experience or clinical evidence.
AnCan cannot and does not provide medical advice. We encourage you to discuss anything you hear in our sessions with your own medical team.
AnCan reminds all Participants that Adverse Events experienced from prescribed drugs or protocols should be reported to the pharmaceutical manufacturer or the FDA Adverse Event Reporting System (FAERS). To do so call 1-800-332-1066 or download interactive FDA Form 3500 https://www.fda.gov/media/76299/download
AnCan’s Prostate Cancer Forum is back (https://ancan.org/forums). If you’d like to comment on anything you see in our Recordings or read in our Reminders, just sign up and go right ahead. You can also click on the Forum icon at the top right of the webpage.
All AnCan’s groups are free and drop-in … join us in person sometime!
Editor’s Pick:Docs finally solve his post-prostatectomy urination ordeal: a surgical clip left in by mistake (bn)
Topics Discussed
Tips to prepare for his first visit to a GU oncologist; choosing between radoncs who disagree on hormone therapy; don’t wait beyond a 0.25 PSA to get a scan; scan first, zap later — not the reverse; his terrible post-prostatectomy urination problems finally explained: a plastic surgical clip got left in after the surgery; after his first Pluvicto round, less bone pain, but middle-of-the-night vomiting; reminder that not everyone needs 6 Pluvicto rounds; his Embr Wave works great — though it didn’t for the fellow AnCan’er who gave it to him; on a trial, he’ll be getting up-front PARP inhibitor along with the ADT for his BRCA mutation — what side effects can he expect?; “tremendous aches throughout my entire body” after second shot of Prolia, and docs saying it’s normal — maybe he doesn’t need the drug so often; good news from an MRI — suspected liver mets are a false alarm.
Chat Log
Michael McCabe · 6:22 PM
Hello everyone!
Jim Marshall, Alexandria, VA · 6:25 PM
Some offlabel info in case you are watching huuricanes and weather. They is a weather model called Ventusky out of the Czech Republic. It has been very accurate, invoke www.ventusky.com it is marvelous. Jim Marshall
Julian – Houston · 6:28 PM
thank you!
Joel Blanchette, Reston, VA · 6:37 PM
Dr. Eblan is my Radiation Oncologist
? · 6:40 PM
PROMISE germline test https://www.prostatecancerpromise.org/?utm_campaign=ANCAN&utm_medium=link&utm_source=Webinar
Joel Blanchette, Reston, VA · 6:58 PM
Dr. Josh Allen is also one of my GU Medical Oncologist
Jim Marshall, Alexandria, VA · 7:17 PM
ORGOVYX.
? · 7:18 PM
Orgovyx (relugolix)
Steve Collins · 7:20 PM
stevecollinsteam@comcast.net
? · 7:23 PM
🎂 🎂🎂 – happy b-day, Bill
Julian – Houston · 7:25 PM
check out https://www.orgovyx.com/
? · 7:31 PM
I can wait to talk if time is short.
Richard Tolbert · 7:33 PM
Thanks everyone, I have to leave the meeting.
Michael McCabe · 7:50 PM
take care guys gotta go…
Gene Siciliano · 8:00 PM
I didn’t realize how long these groups go, and I have to leave. Thanks everyone.
Julian – Houston · 8:09 PM
Thanks again for the great discussion and conversation!
Hi-Risk/Recurrent/Advanced PCa Video Chat, Sep 16, 2024
AnCan is grateful to the following sponsors for making this recording possible: Bayer, Foundation Medicine, Janssen, Myriad Genetics, Novartis, Telix & Blue Earth Diagnostics.
AnCan respectfully notes that it does not accept sponsored promotion. Any drugs, protocols or devices recommended in our discussions are based solely on anecdotal peer experience or clinical evidence.
AnCan cannot and does not provide medical advice. We encourage you to discuss anything you hear in our sessions with your own medical team.
AnCan reminds all Participants that Adverse Events experienced from prescribed drugs or protocols should be reported to the pharmaceutical manufacturer or the FDA Adverse Event Reporting System (FAERS). To do so call 1-800-332-1066 or download interactive FDA Form 3500 https://www.fda.gov/media/76299/download
AnCan’s Prostate Cancer Forum is back (https://ancan.org/forums). If you’d like to comment on anything you see in our Recordings or read in our Reminders, just sign up and go right ahead. You can also click on the Forum icon at the top right of the webpage.
All AnCan’s groups are free and drop-in … join us in person sometime!
Editor’s Pick: Germline BRCA2 Dx may impact treatment decisions (rd)
Topics Discussed
Younger high risk Gent with germline BRCA; is singlet enough for T3c (SVI); retrying daro; drug holiday endures for CHEK2 Gent; FINALLY starting HT 11 yrs after RP; HT effective; persevering w. Kwon… at least until next decision point; Testosterone discussion
