How do we educate the public on ways to afford medications?

[Mrs Helleck]

I recently had a personal experience with my 76 year old mother that opened my eyes to a problem that many be experiencing. The medicare prescription plan has a "donut hole" which as I understand is when the enrollee reaches the first dollar limit on prescription coverage, they then pay out of pocket until they reach another set amount after which they have some additional coverage. What an easy to understand plan for the elder population. My mother is on an injection drug for osteoporosis which she receives twice a year. She was concerned because each injection was $2400 at her PCP's office and that along with her other medications would exceed her coverage placing her in the "donut hole" early in the year. Her insurance agent did some checking and told her the medication cost at the pharmacy would be just under $900 so if her PCP would write a prescription for the medication, my mother pick it up and carry to the PCP's office and have them administer, she would save $1500 for each treatment. The PCP was agreeable to this. My question is how many situations like this occur everyday causing patients to choose between medication and other neccessities? How can we as patient advocates get this information and deliver it to our patients?

[Anna Flaxis, BSN, RN]

If you have social workers, they are a great resource.

I work in a small community hospital and we do not have social workers. I did a google search and found the $4 generic lists for several of the pharmacies in our area, printed them out, and put them in a binder. This way we can quickly and easily look up meds for folks who are concerned about the cost.

[OCNRN63, RN]

http://www.needymeds.org

They provide links to all sorts of patient assistance programs for prescription and OTC meds.

[OCNRN63, RN]

Home Page - NeedyMeds

They provide links to all sorts of patient assistance programs for prescription and OTC meds.

[Irish_Mist, BSN, RN]

Costco has some really good prices on medications especially on generics. My levothyroxine costs me $7 there as opposed to $30 at Walgreens. It is important to shop around to ensure you get the best deal.

[pinkiepieRN]

Costco has some really good prices on medications especially on generics. My levothyroxine costs me $7 there as opposed to $30 at Walgreens. It is important to shop around to ensure you get the best deal.

I actually don't think you even need to be a "member" to get your prescriptions filled at Costco. :)

[suanna]

This is why some of the provisions in the ACA aka"Obama Care" don't get the coverage they deserve. Seniors shouldn't have to search for tips and tricks or handouts to get the medical care they need. The fact that a few companies will offer discounted meds if you know how to work the system just means they are hoping as many people as possible don't work the system and they can make thier fortune. If anyone points out the ethics of charging $8000. for a drug that sells in Europe for $20. they can point out that they "give it away free for anyone who needs it but can't afford it"(by thier standards) If you know what hoops to jump through. Helping patients with the tips and tricks is unfortunately part of my job but it would be much nicer if the system was designed to be fair and affordable for everyone and I could spend my time doing better patient care.

[madwife2002, BSN, RN]

Some of my dialysis patients won't fill their scripts until they have reached the donut hole-neither will they go to the hospital if we need to send them because they will have to pay $$$$$out of pocket

[Ally082]

To answer your question yes this happens all the time no matter what coverage you have. Private insurance may not cover certain high cost injectables at all, meaning you would always pay out of pocket for it no matter what, end if story. Medicare at least try's to cover some of the cost. The out of pocket costs are frustrating, it's like a deductible that comes out of no where so it's important to stay on top of things. Trust me this is not an ACA issue or a Medicare issue. Prescription benefits are complicated and costly to begin with but injectable drugs ( except insulin) are a different ball game all together. They are handled and billed differently and it matters if it's a self injectable or if it will be administered via a prescriber.

Let me explain, you can't purchase some specialty injectable drugs just anywhere. Some high cost injectables the pharmacy can special order and then have the patient take it to the doctor to administer just like your mom did but it may not always be the case.

Some good advice on here, the manufacturers will always help with rebates, discount cards, special offers/programs because they don't want you to find alternatives and trust me they push the insurance companies to cover their drugs but if there is a more cost effective option they may flat out say "Not Covered". Unfortunately, the pharmaceutical industry is all for profit, no one can control that in a free market. The insurance industry has to work with and around big pharma sometimes but the costs are astronomical all around for everyone involved. Pharmacists are great resources for questions like this. They spend half their day on the phone with insurance companies, fighting to get rx claims through..trust me they know exactly how this stuff works.

[Ally082]

Sometimes you can print out the drug formulary, so you have a comprehensive list of what drugs are actually covered by the plan. That way if there is a comparable drug that is covered by the insurance plan the doctor can switch it before a patient even has to deal with the run around.

My mom has done this, she is prescribed an expensive brand name drug that doesn't have a generic. She researched and found other drugs in the same drug class that her insurance would pay for. She asked the doctor if any of the drugs on the list would be ok. They switched her meds and it all worked out. My mom isn't old enough for Medicare and still has these problems. I am learning everything I can so by the time she is on Medicare I can help get her the most cost effective care with as little hassle as possible.

[DoGoodThenGo]

Our local pharmacy (Walgreens) will inform you via your pharmacist when picking up meds about their prescription drug program if they see you are uninsured and or have things that aren't covered by your own. One woman in front of me last week saved $200 on the order she was picking up when the pharmacist explained how the plan worked. IIRC it costs $20 per year to join but again in the case of this customer she got that back in spades in instant savings.

Bottom line is there is information out there and best thing concerned persons can do is research and present findings.

[guest64485]

I wish I had seen this earlier. OP, I am guessing you are referring to Prolia as the injection in-office for osteoporosis? If so, getting it from the physician is covered under the medical, part B, portion of Medicare (not pharmacy, part D). It is buy-and-bill for the physician. Generally if a Medicare patient has a secondary insurance, most secondary insurances cover the remaining 20% copay from Medicare medical part B expenses (not pharmacy part D). Medicare + part B supplemental will generally cover 100% of Prolia (and most other drugs given in-office. Prolia has a benefits investigation form that your doctor can send in which will outline all this information and confirm whether or not her secondary (if she has one), covers medical copays if she is confused, and will give her an estimated cost. By her purchasing the Prolia herself, she is forcing it to instead go through part D pharmacy coverage instead of part B. It seems as though someone told her she would have to go through part D either way which is just not true as I've worked with Prolia and have had Medicare and private insurance Prolia patients in the past.

See this link:Commercial Co-Pay Cards and note how there are two entries for Prolia, one for picking it up at the pharmacy, and one for getting it in-office. Please note that Medicare patients are not eligible for copay cards so that section does not apply to them. This is why a secondary supplemental part B insurance which will cover the remaining cost via medical billing, is so important. Again, this combination usually pays 100% (Medicare = 80%, supplemental = 20%), and that way you bypass Medicare pharmacy part D coverage which has the donut hole, and, may not cover more expensive drugs well.

Private insurance patients can make full use of copay cards, and everyone should check the manufacturer's website to see if their drug qualifies. This can save you $50+/month depending on the drug, especially if it is a more expensive medicine. It is in the manufacturer's interest to have you fill your script with their copay card because your insurance will foot the bulk of the bill.

Those with no insurance should check with the manufacturer as they usually have free drug program that you may qualify for.

In addition, those with insurance may have specific requirements for their pharmacy coverage, such as penalties if you don't fill your script at very specific locations (often times it is mail order, but I have had two patients where their insurance required that they fill their costly drugs at one specific pharmacy (not just any pharmacy in the chain, one specific location).

Those with Medicare getting drugs through part D, or those who can not afford the copays of the drugs without copay card programs can check with various charities online for help, such as needymeds which was already mentioned, and there are many others out there, such as healthwell, etc, BUT, these usually give a cap of ~$2,000 per year, which may not be enough, and the available funds run out very quickly. These charities usually replenish their funds and slots for people at the beginning of the each year. I wouldn't be surprised if the majority of these funds are already promised and that these places are closed for new patients till 2015.

This whole system took me a long time to understand and be able to utilize for my patients. (I still don't fully understand Medicare replacement cards though, if anyone has insight on that) If it is hard for those in healthcare to know all the caveats, think of how confusing it must be for the patients! This is one of the reasons that I really dislike the healthcare in the US. At least with single payer the rules would be more widely known and we would be able to streamline how to help patients get the care they need.

edit: the $4 list at Target/Walmart as was mentioned earlier is also a fantastic choice for patients with any, or, no insurance

[RainMom]

For the past several yrs when my mother hits the donut hole, we then use a Canadian pharmacy. Purchase price is half the cost (sometimes better) than if she had to pay out-of-pocket locally. She usually hits her limit towards the end of the yr anyway & wouldn't reach "the other side of the donut hole" for coverage to resume. We also shop around locally; the cost of Lovenox varies quite a bit.