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Does Medicare Part D cover prescriptions for clinical trials?

Dear Toni: I am fighting liver cancer. I turn 65 in September and am covered under my wife’s health insurance through her employer. I am participating in a clinical trial for a medication that is curing my cancer — it costs over $12,000 per month, but I pay $0.

I am concerned about what to do when I enroll in Medicare and if I will be in Medicare’s infamous “doughnut hole” since this is a clinical trial. I am not planning to enroll in Medicare until my wife, Sarah, retires when she turns 65 in two years.

Are clinical trial prescriptions covered under Medicare drug plans? What are my options? — Lincoln, Tampa, Florida.

Dear Lincoln: What a smart decision you made to stay on Sarah’s employer benefits, because you both can enroll in Medicare Parts A and B when she retires at 65. At that time, you will be eligible for a special enrollment period, avoiding a Medicare Part B penalty, and will be able to enroll in a Part D prescription drug plan. She will be enrolling in Medicare during her initial enrollment period.

Exploring Part D and prescription drugs is one of the most important Medicare topics. Lincoln, you would go into the “doughnut hole” the second you order the prescription that costs over $12,000 per month if you were not in a clinical trial.

In 2024, the doughnut hole begins once the actual cost of a person’s prescriptions reaches $5,030 and ends when one has spent $8,000 out of pocket; then the catastrophic coverage phase begins. As of Jan. 1, the new catastrophic coverage cost is zero out of pocket for the Medicare beneficiary and the Part D plan, with Medicare picking up all costs.

You should always enroll in the Medicare Part D plan that covers all of your prescriptions, even though the most expensive prescription is covered by a clinical trial program and currently costs you nothing. There may be a time when that expensive prescription is no longer covered by the clinical trial, and without the right plan you will have to pay the doughnut hole cost.

Whether your Part D drug plan will pay for a medication used in a clinical trial depends on if it is covered by the plan or can be classified as a Tier 5 prescription that costs more. Then you would leave the doughnut hole and go into catastrophic coverage immediately.

For those enrolled in a Medicare Advantage plan seeking clinical trials, the “Medicare &You” handbook states: “Original Medicare may cover some costs along with your Medicare Advantage plans. Contact your plan for details.”

Enrolling in Part B when your wife retires is a good option, Lincoln. You and Sarah will qualify for a Medicare supplement plan during your six-month Medigap open enrollment period without having to answer health questions. This period starts the month your Part B takes effect.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.

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