Does Medicare Cover Xtandi?

If you or a loved one are battling prostate cancer you might have heard about Xtandi (enzalutamide). This medication is often prescribed to help manage advanced prostate cancer. But here’s the burning question — does Medicare cover Xtandi? Well lucky for you that’s exactly what we’re here to dive into. Let’s break it down in human terms and add a dash of humor to keep things light because hey life’s serious enough!

What is Xtandi Anyway?

Xtandi is a medication used to treat certain types of prostate cancer. It works by blocking the effects of androgens (male hormones like testosterone) which can fuel the growth of cancer cells. It’s often given to men with advanced prostate cancer who either don’t respond well to other treatments or whose cancer has spread to other parts of the body. But we’re not here for a chemistry lesson right?

How Does Xtandi Work?

• Blocks testosterone receptors: Basically it tells testosterone “Sorry pal you’re not getting in here!”
• Slows cancer growth: By stopping testosterone from doing its thing Xtandi can slow down the growth of cancer cells.
• Oral medication: Xtandi comes in the form of capsules you take by mouth. So no needles involved! Phew!

Does Medicare Cover Xtandi?

Alright let’s get to the juicy part — Does Medicare actually cover this stuff?

Medicare Part D and Xtandi

Here’s the deal. Xtandi is considered a prescription drug so it falls under Medicare Part D. But here’s the catch (there’s always a catch isn’t there?) Not all Medicare Part D plans cover Xtandi and even when they do you might still have some hefty out-of-pocket costs.

Here are some key things to consider:

1. Check your plan: You’ll need to check your specific Part D plan to see if Xtandi is on the formulary (aka list of covered drugs).
2. Out-of-pocket costs: Even if it’s covered you’ll likely have copayments or coinsurance and Xtandi isn’t exactly cheap. You might want to sit down for this one. The cost can run thousands of dollars per month without insurance.
3. Coverage gap (aka the “donut hole”): If you fall into the coverage gap (where Medicare pays less and you pay more) your out-of-pocket costs could skyrocket. It’s a bit like losing your glasses in the ocean – not fun at all.

Henry Beltran owner of Medicare Advisors Insurance Group LLC says “Many people are shocked at how expensive Xtandi can be even with insurance. It’s really important to understand your plan and what it covers upfront so there are no surprises down the line.”

Medicare Advantage Plans and Xtandi

Some Medicare Advantage plans (which are Medicare plans offered by private insurers) include Part D coverage. If you have one of these plans they might cover Xtandi but as with Part D coverage will vary depending on your specific plan.

Prior Authorization

Oh and don’t forget some plans require prior authorization before they’ll cover Xtandi. This means your doctor has to get approval from your insurance company before you can get the drug. It’s kind of like when you were a kid and had to ask your mom for permission to go to a friend’s house. Only in this case it’s your doctor and the insurance company and they’re playing hardball.

Out-of-Pocket Costs for Xtandi

Let’s talk about the big elephant in the room—how much is this going to cost you?

Without Medicare

If you don’t have any insurance coverage Xtandi can cost up to $14,000 per month. That’s like the price of a small car every month but without the new car smell.

With Medicare

Even with Medicare Part D you’re likely looking at some hefty costs. Depending on your plan and the stage of your prescription drug coverage (like whether you’re in the initial coverage period or that dreaded “donut hole”) you could end up paying hundreds or even thousands of dollars out of pocket.

• Initial Coverage Stage: You’ll pay a copayment or coinsurance (usually a percentage of the drug’s cost).
• Donut Hole Stage: You’ll pay 25% of the drug’s cost (but 25% of $14,000 is still…a lot).
• Catastrophic Coverage: After you’ve spent a certain amount (in 2024 it’s about $8,000) Medicare will step in to cover 95% of the costs.

Are There Any Cheaper Alternatives to Xtandi?

Sadly there isn’t really a generic version of Xtandi on the market yet. But there are some other medications that might be used in its place depending on your specific condition. Some of these include:

• Zytiga (abiraterone)
• Lupron (leuprolide)
• Firmagon (degarelix)

Talk to your doctor about your options but keep in mind they all have their own sets of side effects and quirks. It’s kind of like choosing between cars — sure one might have heated seats but do you really need a backup camera? Wait wrong metaphor.

How Can You Save Money on Xtandi?

Nobody likes paying more than they have to especially for life-saving meds. So here are some potential ways to save a few bucks on Xtandi.

1. Medicare Extra Help: If you have limited income you might qualify for Extra Help which could significantly lower your prescription costs.
2. Xtandi Patient Assistance Program: Pfizer offers a patient assistance program for those who can’t afford the drug. Worth looking into if you’re struggling with the cost.
3. Shop Around: Different Part D or Medicare Advantage plans have different formularies so shopping around during open enrollment can sometimes help you find a plan with lower costs for Xtandi.

Henry Beltran adds “I always tell my clients to explore all their options. It’s a good idea to compare plans during open enrollment because one plan might cover your medication at a fraction of the cost.”

Potential Drawbacks of Xtandi (With a Smile)

We wouldn’t be doing our job if we didn’t talk about the potential downsides of Xtandi. It’s a powerful drug but like that fancy sports car it’s not without its flaws.

• Fatigue: You might feel like you’ve run a marathon when all you did was binge-watch your favorite show.
• Hot flashes: It’s like your body thinks it’s in a sauna at the most inconvenient times.
• High blood pressure: Xtandi could crank up your blood pressure like a teen getting their first speeding ticket.
• Seizures: In rare cases Xtandi has been known to cause seizures. So if you feel funny don’t just brush it off like a weird dream.

Final Thoughts on Medicare Coverage for Xtandi

Xtandi can be a game-changer for men with advanced prostate cancer but it doesn’t come cheap and Medicare coverage can be complicated. Whether you’re on Part D or a Medicare Advantage plan it’s important to understand your coverage options and be prepared for some potentially significant out-of-pocket costs.

But don’t let that stress you out. At Medicare Advisors Insurance Group LLC we’re here to help you navigate the twists and turns of Medicare coverage like your very own GPS. Give us a call and we’ll make sure you’re on the best path to getting the care you need.

“We want to make sure our clients know all their options so they can make informed decisions” says Henry Beltran “Xtandi is a great medication but we know the cost can be overwhelming. That’s why we’re here to help.”

Key Takeaways

• Xtandi is covered by Medicare Part D but not all plans cover it.
• Costs can be high — especially if you hit the dreaded donut hole.
• Consider programs like Extra Help and manufacturer assistance if costs are too high.
• Always compare Medicare plans to ensure you’re getting the best coverage for your meds.

So whether you’re asking “Does Medicare cover Xtandi?” or “Why is my car beeping at me?” we’ve got you covered on at least one of those fronts. (Hint: It’s the Medicare one).