This week’s questions from Duane & Ronnie
Duane: My wife has been an MS patient for over 20 years. Her treatment during that time has been 40mg of Copaxone, injected 3 times per week. Currently, she has excellent drug coverage, but she’ll lose that when she turns 65. Neither she nor her neurologist wish to change her treatment going forward because it’s been successful and well tolerated. Unfortunately, it’s a very expensive drug. We fear it will prove a significant financial burden to us if we need to fund it out of pocket. Are there any Medicare drug plans for her? What is the worst-case scenario for us?
Ronnie: I am wondering if you have any advice regarding a Medicare drug plan for someone who is on Insulin. My brother is currently working but wants to retire. His employer provided health insurance covers the cost of his Insulin and another expensive medication. He’s investigated his Medicare options and discovered that Insulin costs will be very high. He’s concerned that it will be too expensive for him to retire. Are there options for individuals whose medications are costly?
Answer
Duane’s Question
I find it very unfortunate that people who have worked and paid taxes all their lives and deservedly want to retire must deal with the Medicare Prescription Donut Hole, something we were told was going away but turned out to be completely false. No other type of health insurance; ACA, employer, Medicaid, or VA, has the Donut Hole, where after exhausting $4,430 worth of retail medications, costs increase dramatically. What’s happened is the average retail cost of brand name medications has risen as much as 1,000% since 2008, from around $125 for a 30-day supply to approximately $550. Non-insulin injection meds that are now being widely prescribed are over $1,000! When someone who takes one falls into the Donut Hole, which would happen in only four months, the costs of their diabetes drugs increase from an average of $45 to $250/month.
Duane, there are indeed Medicare Part D plans that cover Copaxone and in the worst-case scenario, you will end up spending in the neighborhood of $5,000 a year for it. That is an unfortunate possibility because I believe your income is over the limit for PACENET and for what are known as Patient Assistance Programs (PAP) that are sponsored by drug manufacturers. However, we have an employee, Tony DiRoma, our Prescription Drug Caseworker, who is extremely good at hunting ways to bring costs of medications down, and if your wife becomes a client, he will turn over every stone for her.
On a related topic, drugs that are injected or infused in an outpatient setting such as Remicade and Prolia, which are becoming quite common, are covered by as a medical benefit as opposed to Part D (prescription), which means those on Supplements don’t pay a dime for them once their $233 deductible has been met. However, with all Advantage Plans, there is a 20% coinsurance for Part B medications which can be extremely costly. There would be very few circumstances where we would advise someone who needs a Part B drug to choose an Advantage Plan.
Ronnie’s Question
As far as Ronnie’s brother, the good news is in 2019, the Medicare Part D Senior Savings Model was introduced. This program caps the cost of certain insulins to $35 per month, waives any deductibles, and keeps the cost at the same $35 even in the Donut Hole. There are several companies who participate and I’m sure we can find a plan that works. The bad news is there aren’t any plans, Stand Alone Part D or Advantage, that eliminate the Donut Hole, so we would need to find alternative means to lower costs of the other expensive medication Ronnie’s brother is taking. But again, The Health Insurance Store is very experienced in doing just that and I’m confident he will be able to retire when he wants to.
Several brand name diabetic manufactures made their Patient Assistance Programs easier to qualify for than they were a couple of years ago as a sign of good will during the COVID lockdowns and there’s an extensive list that of drugs that they are still providing at no cost. I hope these companies will keep the more liberal qualifications in place as it’s been an absolute blessing for many of our clients who wouldn’t be able to afford their medications otherwise.
The high cost of prescriptions and the confusion as it relates to Medicare aren’t going away anytime soon. It’s yet another reason to choose The Health Insurance Store when it’s time to go on Medicare for the first time or when a review of a current plan is in order, which should be done almost every Annual Election Period, something we do for all our clients. Choosing the wrong plan or not getting sound advice can be extremely costly. Consultations with our licensed and experienced agents are always no cost as well as plan reviews and guidance when it comes to keeping out-of-pocket medical and prescription costs to a minimum, which is so important as inflation continues to make everyday living more costly, especially for seniors on fixed incomes.
Thank you!
If you have any questions or concerns regarding this column topic, or would like to make an appointment for a no-cost consultation, please feel free to give us a call – we would be happy to help. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.
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