Medicare Part D
Effective January 2006, persons with Medicare became eligible to purchase Medicare Part D Prescription Drug Coverage by: 1.) joining a Medicare Prescription Drug Plan by paying additional premium or by 2.) joining a Medicare Advantage Plan such as an HMO ( health maintenance organization) or a PPO (Preferred Provider) or a Medicare health plan that provides prescription insurance.
Things to consider when obtaining Medicare D coverage:
- Coverage: Does the plan cover the medications on your list?
- Cost: May include: a.) monthly premium b.) annual deductible and c.) coinsurance and copayments. Persons falling under certain income guidelines may qualify for "extra help" also known as low income subsidy. This helps pay for the monthly premium, annual deductible, coinsurance and copayments.
- Convenience: Some plans allow for obtaining prescription through the mail.
- Coverage gap: (Also known as the doughnut hole) This is a very important but poorly understood aspect of the Medicare Part D plan. Essentially, in any given year, when prescription drug cost reaches a certain amount, ( $2,510.00 in 2008), the patient is responsible for 100% of the cost of medications for the next $3,216.00. Once this total of $5,726.00 is reached, Medicare Part D catastrophic coverage kicks in and pays for 95% of drug cost. This doughnut hole was built in by Congress to limit taxpayer cost while at the same time ensuring that persons with extremely high drug cost can get assistance. Individuals who qualify for " extra help" do not have a coverage gap.
- Note: The monthly Medicare D premium must be paid during the doughnut hole period.
Some Strategies for Negotiating the Doughnut Hole and High Drug Cost:
- Obtain coverage gap insurance ( in addition to regular monthly premium.) Many of these plans pay only for generic drugs, so check what you are buying.
- Go bare and self insure by setting aside savings equal to the coverage gap amount each year.
- Talk to your health care provider about generic medications or class equivalent drugs.
- Monitor prescription drug expenditure to avoid the doughnut hole.
- Check with WalMart Pharmacy if your medication is in their generic medication $4.00/month supply list. Other pharmacies such as Target Pharmacy offer a price match. Costco Pharmacy also offers the lowest mark-up on many generic medications.
Understanding Prescription Drug Tiers:
Medicare requires that all drug coverage plans cover at least two drugs in each category of drugs except that they are not required to cover certain drugs such as sedatives ( barbiturates and benzodiazepines), weight loss or weight gain drugs, drugs for erectile dysfunction and over the counter medications. Some prescription drug plans may limit the quantity of medication per fill, require prior authorization for certain medications or request stepwise therapy where one must try a similar or less expensive drug before progressing to a more expensive drug. Prescription drug plans also classify medications in what is known as a tier system.
- Tier 1 covers most generic medications and has the lowest copayment.
- Tier 2 covers preferred brand name prescription medications ( usually brand name medications deemed to be equally effective but less expensive as similar drugs) and has medium copay.
- Tier 3 covers non-preferred brand name medications and has a high copay amount.
- Specialty tier covers very expensive unique medications and have the highest copay.
Generic medications must be bioequivalent to the brand name and has the same active ingredient, efficacy, and safety profile as the trade brand medication. They undergo the same oversight by the Food and Drug Administration as its brand name equivalent.
It is also helpful to discuss bioequivalent medications with your health care provider. Talk about the intended treatment outcome and whether or not a less expensive medication will do just as well. For example, will aspirin have the same therapeutic outcome as more expensive blood thinners? Will a less expensive ace-inhibitor work just as well as other brand name blood pressure medication.
Patient Assistance Programs
When brand name medication is essential, talk to your health care provider about patient assistance programs. Drug manufacturers have agreed to provide medically necessary medications to persons falling below certain income guideline ( different from drug company to drug company) and who do not have prescription insurance coverage. Persons who are in the doughnut hole may qualify for this program. This requires that your physician and you complete an application form. Proof of income is usually required but may differ with each patient assistance program.
Talk to your pharmacist about discount prescription drug plans. These plans do not require a premium and usually provide the patient with a discount card where medication cost is discounted.
And don't forget the incentives such as gift cards and rebates that some pharmacy chains give out for obtaining your business. Every little thing helps.
A Caution About Buying Prescription Drugs Online
There is no substitute for the services of a pharmacist that you can ask questions of and who can counsel you on your medications. Online drug stores do not have the regulatory oversight that brick and mortar pharmacies do. Be suspicious of medications purchased this way.