Medicare and Big Pharma

Medicare and Big Pharma are quite a combination. This blog will explain how some of the new medications on the market are treated for those on Medicare.

This situation is near and dear to this blogger’s heart.

Anyone on Medicare should know that certain diseases and the appropriate medication can be very expensive putting many seniors in the drug donut hole or gap during the year. All Medicare recipients are aware of this situation and act accordingly. This is particularly true when one has diabetes or other debilitating diseases using expensive medications under Part D of your Medicare plan.

For the sake of discussion, let us say you suffer from an incurable disease but through medication, you can live a normal life. We will use Rheumatoid Arthritis as an example and will refer to it at RA during this blog.

If you have RA, you know it can cause many other problems for you medically and the medications available are very expensive. Once diagnosed, the Rheumatologist will run you through many of these medications until the best one for you is found. That best one can change over the years for many reasons not necessary during this discussion.

For sake of discussion, you are put on some very inexpensive medications that over time need to be changed. Once you have reached this step, the expensive biologics come into play. All these biologics are very expensive, usually costing several thousand per month. Many of Big Pharma offer special arrangements whereby you can get the medications with a no-cost or copay card. What would normally cost $3-4 thousand per month may only cost $10 using this copay or nothing depending on your circumstances and how Big Pharma handles the situation.

If you are on any form of government insurance (Medicare, Tricare, VA, Medicaid, etc.) there are two options; a free drug program, or if you do not qualify, a drug copay card. (Income is a qualifier, but the amount varies by the drug company) The free drug card is outside the insurance so for Medicare recipients there are no charges against Part D. If you get the drug copay card that does go against Part D coverage and you will be in the donut hole)

The question is how to deal with this situation if you are on Medicare. It is very simple or could be extremely complicated. This depends upon both your Medicare insurance type and whether you take a pill or shot yourself or have it done in a Doctor’s office? If you have Original Medicare, with or without a supplement or an MAPD plan then the medication can be administered in the Doctor’s office. Your cost is 20% of the cost of the medication under Part B Medicare. Many supplements pay what Medicare did not pay leaving the recipient with no cost other than the premium for the supplement. Any medication that must be administered in the Doctor’s office is considered under Part B. So that $4000 medication @ 20% still costs $800 per month.

If you administer the medication yourself by taking a pill or self-injection, then it falls under Part D and subjects to the several phases of Part D including the donut hole and catastrophic coverage. Either you get the medication at no cost (Because you are on Medicare and qualify by income) or have a copay card for $10.00 per month.

I have personally seen a situation where the medication was $4000 per month and the client’s income was over $125,000 and they still qualified for the free drug program which is outside of Medicare. The only way to find out is to apply for the free drug plan.

The process is quite simple, if your doctor recommends you for a specific medication, they contact the manufacturer to start the process. Then the manufacturer sends you forms to complete which includes your income. Then the evaluate your specific situation and either approval or disapprove based on your overall financial situation. (That also depends on the cost of the medication, as each situation is different.)

This assistance from Big Pharma helps many seniors who suffer from catastrophic illnesses to stay alive and not have huge medical or pharmacy bills. Those under Medicare age get a copay card and pay on average about $10 for the medication monthly.

Big Pharma has many detractors and some of the reasoning is correct but the assistance they provide to seniors is unreplaceable and worthy of us mentioning this to all seniors.


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