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Part D Stories
February 12, 2009 • Volume 9, Issue 6
The following are a sampling of stories that were submitted to the Medicare Rights Center over the last month. If you or someone you care for has hit the doughnut hole or faced other financial or bureaucratic obstacles in trying to obtain medicine, submit your story here. Congress and the Obama administration need to know the real story about Part D.
Lung transplant eight-plus years ago. Not on Medicare at the time. I am now, plus supplemental. I pay a lot each month for my insurance. I just went online to my Part D plan to get a refill on my Prograf 5mg. They are charging me $3100.00 for the first three months this year! My meds are extremely expensive. I am so tired of using my savings (stupid me for having some) to stay alive. I am thinking quite seriously of just not taking them anymore.
Here it is February and I’m already stressed thinking about June getting here and having to pay for all my medications. My husband and I try our best to live on $21,000 a year and pay for our insurances. My medications will be well over $600 a month in July and I will not take anything but my heart medication and will have to trust the good Lord that my diabetes and hypertension will not get so bad that I will have to go to the hospital. I have cried, begged and been humiliated by the local state office of human resources and told there was no help for us. I have called Medicare and my drug plan and have not heard anything back. They told me they would check and mail me out a form and that was back in November of 2008. I am tired and just don’t know what to do.
Terre Haute, IN
I have been enrolled with a Medicare Part D plan since they started. This year I changed Part D plans. I have been on Avapro, an antihypertensive, for years, but my new plan would not cover it because they said I had to go through a step program. I explained to them that I had been on other medications and that this one has worked for years but they would not alter their decision. They would cover 2 similar medications, one more expensive and one the same price. I am now going through a whole recheck to be sure I tolerate the new medication, it is effective and there are no other problems, all of which cost Medicare more money than if they were to allow the continuation of a medication that I have been on and is on their formulary. I am sure there are many other patients who make a change in plan and are faced with this unnecessary step program if they have been on the medication already. If the medication is new then I can understand the need for a step program, but there should be some continuity of care when a Medicare recipient changes plans and should be able to continue their current medication if it is on the formulary. I filed an appeal and grievance with the plan but the plan would not change their decision. I ended up having to change medication and am now going through more checkups and labs to make sure the medication is appropriate.
My wife is diagnosed as end stage emphysema and is on variety of medications, nebulizer and on oxygen 24/7. One of her medications is the Advair disc inhaler. A 3 month supply was ordered through her Part D plan and, because it brought us into the "doughnut hole," the charge was $711.41, with the cost of drug shown as $939.02. I inquired as to what the cost was based on when the same drug same amount can be purchased from Canada at under $300.00, I was told it was because of the FDA’s involvement to protect us in the manufacture of medications. When I pointed out that Advair is manufactured in England so why would the product differ depending on what country it was shipped to, I could not get a reasonable explanation. It is ironic that my wife would undoubtedly qualify for an electric scooter because she is wheelchair bound but medication needed for her breathing falls into the doughnut hole nightmare.
I am diabetic and take two types of insulin. My doctor changed one of my insulin prescriptions and I was advised by the Part D plan customer service that the new prescription for insulin was on their formulary. But Costco charged me the entire price for the insulin, $86.25. When I questioned them, they said they had called the Part D plan and were told that I had fallen into the doughnut hole. I knew that I had not since I kept an Excel spreadsheet with detailed cost of all medicines. The Part D plan told me that it would take 45 days to review the case since it was so complex and they would get back to me. Anxiously unable to wait the 45 days, after 3 weeks I called them back to see how my case was progressing and was told by a representative that “I wasn’t in the doughnut hole, that they could look at the screen and tell that. The prescribed insulin was not on their formulary.” A customer service rep said all I needed to do was write a letter and ask that the insulin be placed on their formulary for future use and it was not even necessary to have the doctor do it. But after following all the instructions, my Part D plan still refused the request. I then asked that they remove the charges from my OOP [out-of-pocket] expenses since that transaction was going to put me in the doughnut hole. They would not do it even though I paid the entire cost of the prescription and Costco is unable to perform a reversal of a prescription after 1 week. This is only one of several problems I had with my Part D plan.
I enrolled with another plan for 2009 but I am certain, after reading your article, that I will pay inflated prices there also. I take 9 prescription medications plus 4 OTC medicines. The two vials of insulin together cost $172.06 plus $40 co-pay (all together $212.06) per month. So if I want to avoid the doughnut hole, I basically have little coverage left for any drugs after purchasing the life-sustaining insulin. I will have the rest of the name brand drugs filled outside of the country and the generics ($4) will come from the big-box retailers. I can assure you that I am not alone in this situation. Seniors need help ASAP.
It is a shame that senior citizens are being taken advantage of by greedy insurance companies and elected officials who are allowing it to happen. Our drugs should be dispensed through Medicare with fair prices. America is by far the richest country in the world and its seniors should not have to decide whether to buy medications or food. I am contacting my state’s senators and rep in Washington urging them to co-sponsor the Medicare Prescription Drug Savings and Choice Act.
“A Medicare-administered prescription drug benefit has the potential to lower drug prices for people with Medicare and to reduce the overall cost to Medicare of drug coverage. A national, evidence-based formulary for a Medicare drug plan can help guide doctors to prescribe in a way that improves health outcomes, reduces costs and facilitates a fair and efficient appeals system.”(The Best Medicine: A Drug Coverage Option Under Original Medicare, Medicare Rights Center, October 2007)
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Medicare Part D Appeals Help for Advocates Is Here!
Medicare Rights Center’s new Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process offers an easy-to-understand, comprehensive overview of the entire appeals process, including real-life case examples, a glossary of important appeals terms, a sample protocol for advocates, and links to important resources.
Register for a FREE copy of this great resource.
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Medicare Part D Monitoring Project
would like to hear about your experience, or that of someone you know, enrolled in a private drug plan. With information about what the issues are with Medicare Part D, we will be able to demand that those problems be fixed. Medicare Rights Center
Submit your story at http://www.medicarerights.org/issues-actions/tell-your-story.php.
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The Louder Our Voice, the Stronger Our Message
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Asclepios—named for the Greek and Roman god of medicine who, acclaimed for his healing abilities, was at one point the most worshipped god in Greece—is a weekly e-newsletter designed to keep you up-to-date with Medicare program and policy issues, and advance advocacy strategies to address them. Please help build awareness of key Medicare consumer issues by forwarding this action alert to your friends and encouraging them to subscribe today.
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The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.
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