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Insurance Information

Private Insurance

You may have health insurance through an employer or a personal policy. The benefits of insurance plans vary widely. Insurance plans may pay some or all costs for your transplant, including hospital costs, lab tests, medicine, and follow-up care.

The financial team at your transplant center will probably contact your insurance company to review your benefits. The financial coordinator should be able to tell you what is covered and what is not. You may need to call the insurance company or talk to your employer if you have specific questions about your insurance coverage.

Medicare, Medigap, and Medicaid

Medicare

Medicare is a federally funded insurance program available to permanent residents of the United States who are:

  • Age 65 or older, OR
  • Under 65 with disabilities, OR
  • Diagnosed with end-stage renal disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)


There are 4 different parts to Medicare:

  • Part A offers coverage for inpatient costs (eg, in a hospital or skilled nursing facility)
  • Part B offers coverage for outpatient care as well as coverage for some prescription medications, including some anti-rejection medicines
  • Part C (also referred to as Medicare Advantage) offers coverage for both medical and prescription costs, but is offered through private insurance companies
  • Part D offers coverage for certain prescription medicines through private insurance companies


Medicare can be confusing, particularly when it comes to coverage for medicines. Medicare covers immunosuppressive drugs if the transplant was covered by Medicare or an employer or union group health plan was required to pay before Medicare paid for the transplant. Coverage varies depending on which part of the program you are enrolled in.

Part B provides coverage for anti-rejection medicines if you had Medicare Part A when you had your transplant, you had your transplant in a Medicare-approved transplant program, and you have Medicare Part B coverage. However, if you didn't have Medicare Part A when you got your transplant or if you didn't have your transplant in a Medicare-approved transplant program, your anti-rejection medicines will not be covered by Part B.

Part D can also be confusing. It is an entirely optional program. To be eligible, you need to:

  • Have Part A and/or Part B
  • Pay premiums and any deductibles in addition to the premiums and deductibles you may be paying for other parts of Medicare


Part D may cover immunosuppressive drugs if they aren't covered under Part A, Part B, or Part C. Medicare Part D has a gap in coverage known as the donut hole. Once you have reached the initial coverage limit established by Medicare, you become responsible for a significantly greater portion of the costs of your medicines while also continuing to pay the Medicare Part D premiums.

Fortunately, there is a limit on how much money you will have to spend out of your own pocket. When you reach this limit, you may be eligible for catastrophic coverage and you will only be responsible for a smaller percentage of your medication costs. This cycle repeats each calendar year.

For additional information about Medicare and prescription medication coverage, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to speak with a representative about your specific needs.

Medigap

Medigap insurance is supplemental insurance that covers gaps in the basic Medicare plan. To search for policies in your area, visit the Medigap Policy Search page or call the Medicare Service Center at 1-800-MEDICARE (1-800-633-4227).

Medicaid

Medicaid is a joint federal and state health insurance program. It helps those with low incomes pay for some or all of their medical bills. Coverage and reimbursement will vary from state to state.

Those with Medicaid may have coverage for all of their immunosuppressive medicines; however, some states will not cover a transplant if you have your surgery at a transplant center that is outside of the state in which you live.

For additional information about Medicaid, visit the Medicaid website.

Those who have Medicare and who qualify for some level of Medicaid benefit are referred to as dual eligible. The level of Medicaid benefits for a dual eligible varies based on financial need. Talk with your social worker or financial coordinator for more information.

This is a general summary of coverage, and is not a substitute for individual advice. This information may change, and you should always verify what information is applicable to you and your particular situation.