Yes, Calquence (acalabrutinib) is generally covered by most Medicare and government insurance plans. Coverage can vary depending on your specific Medicare plan and its formulary, but it is typically included.
Understanding Calquence Coverage Under Medicare
Calquence is an oral medication used to treat certain types of cancer, such as chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL). As a prescription drug, its coverage under Medicare primarily falls under specific parts designed for medication costs.
How Medicare Parts Cover Prescription Drugs
Medicare is divided into several parts, each covering different types of healthcare services. For prescription drugs like Calquence, two main parts are relevant:
| Medicare Part | Coverage Type | Potential Calquence Coverage |
|---|---|---|
| Part B | Medical Insurance | Typically covers certain provider-administered drugs (e.g., infusions in a doctor's office or clinic). Less common for oral medications. |
| Part D | Prescription Drug Plans | The primary source of coverage for self-administered prescription drugs, including oral medications like Calquence. Offered by private insurance companies approved by Medicare. |
| Part C | Medicare Advantage (MA) Plans | These plans combine Part A, Part B, and often Part D coverage into one plan. If your MA plan includes prescription drug coverage, it will cover Calquence according to its formulary. |
Since Calquence is an oral capsule taken at home, it is most commonly covered under a Medicare Part D Prescription Drug Plan or through a Medicare Advantage Plan (Part C) that includes prescription drug coverage.
Factors Influencing Coverage and Costs
Even with coverage, the actual cost you pay for Calquence can vary significantly due to several factors:
- Your Specific Plan's Formulary: Each Part D or Medicare Advantage plan has a formulary (a list of covered drugs). Calquence must be on your plan's formulary to be covered.
- Drug Tiers: Plans often place drugs into different "tiers," with higher tiers usually having higher copayments or coinsurance. Specialty drugs like Calquence may be in a higher tier.
- Deductibles, Copayments, and Coinsurance: You will likely be responsible for a deductible (the amount you pay before your plan starts to pay), and then copayments (a fixed amount) or coinsurance (a percentage of the drug cost) once your deductible is met.
- Prior Authorization: Many plans require prior authorization for high-cost or specialty medications like Calquence. This means your doctor must get approval from your plan before you can fill the prescription.
- Pharmacy Network: Your plan may require you to fill your prescription at a specific network pharmacy or through a mail-order service.
- Coverage Phases: Medicare Part D plans have different coverage phases (deductible, initial coverage, coverage gap/donut hole, and catastrophic coverage), which affect your out-of-pocket costs throughout the year.
- Low-Income Subsidies (LIS): Individuals with limited income and resources may qualify for Extra Help, a Medicare program that helps pay for Part D premiums, deductibles, and co-payments.
Steps to Confirm Your Calquence Coverage
To get precise information about your coverage and potential costs, it's recommended to:
- Check Your Plan's Formulary: Review your Medicare Part D or Medicare Advantage plan's drug list (formulary) to see if Calquence is covered and at what tier.
- Contact Your Medicare Plan Directly: Call the member services number on your insurance card. They can provide detailed information about your specific benefits, including any prior authorization requirements or cost-sharing for Calquence.
- Talk to Your Doctor or Pharmacist: Your healthcare provider can help you understand the prescription process and work with your insurance company. Your pharmacist can also provide information about coverage and costs.
- Explore Financial Assistance Programs: The manufacturer of Calquence and various non-profit organizations offer patient assistance programs that may help reduce out-of-pocket costs for eligible individuals.
Understanding your specific Medicare plan's details is crucial to accurately determine your coverage for Calquence and estimate your financial responsibility.
For more information about Medicare prescription drug coverage, you can visit the official Medicare website: Medicare.gov - Prescription Drug Coverage (Part D)
