by Gabriel Levitt, President, PharmacyChecker.com and Prescription Justice | Nov 13, 2015 | Medicare Drug Plans
In this post, we’ll give you some snapshots of consumer frustration, pulled from www.MedicareDrugPlans.com (a website operated by PharmacyChecker.com), about the problem of medications getting dropped from Part D Plans and tell you what is and is not actually permissible. I believe this practice is well characterized by the phrase “bait and switch.” Just listen to Riley from California talk about Blue Shield Medicare Enhanced Plan:
“Keep changing the drugs in the formulary. Just get stabilized on a drug and they drop it from the formulary or charge high tier prices. Then you start on a different drug fine one that works then it is no long covered in next formulary. There is no concern for the patient doesn’t matter to them if you wind in the emergency room at a cost of many thousands of dollars and patient’s pain and discomfort. It is not their problem the medical coverage has to pay for it and the drug coverage have saved themselves some money at the cost of medical coverage, medicare and the patient.”
Before choosing a plan, most experts encourage people to research plan premium and deductible costs, pharmacy networks, gap coverage, and – most importantly – which drugs are covered in a plan’s formulary. The beauty of the government’s Medicare Plan Finder is that you get to actually type in your medications and find plans that cover those drugs. So imagine doing just that: you look on the government’s site and find a plan that covers the three medications you take. You’ve taken THE BAIT and enroll in that plan. Come January all is well, your costs are manageable and you pat yourself on the back for a research job well done. Then in March – THE SWITCH – you find out that the brand name drug prescribed by your doctor, which has worked well for you for years, will no longer be covered and you either have to take an alternative drug that is covered or pay for the drug as an out-of-pocket cost.
Is this type of bait and switch legal? Yes. After reviewing the regulation, 42 CFR 423.120, the law is clear that Part D plan sponsors can take a covered drug off its formulary. There are some caveats but I don’t believe they compensate for how unfair these formulary changes are. The plan must either give you 60 days notification before the formulary change goes into effect or if you go to the pharmacy for a refill the plan must cover the drug with a 60-day supply. In other words, they need to warn you about the bait and switch to give you time to figure out your next move.
Some enrollees seem to have had good experiences with a plan and then everything just tanks. We learn from one Michigan resident about an experience using the Cigna-HealthSpring Rx Secure plan
“After 5 years in plan they dropped coverage on 3 of my 5 scripts, no value now, cheaper to buy all on my own”
Some consumers gave greater details about the costs incurred due to these bait and switch practices. Here’s what one Floridian said about AARP MedicareRx Saver Plus:
“They dropped an important Blood Pressure medication (Micardis) for 2015 as well as others. Out of pocket cost went from 2013 -$60.00, then in 2014 $120.00 now in 2015 over $545.00 for 90 day supplies of Micardis through Optum RX their online med source. Too late for me, will look for a better Part D source come next year.”
Our friend from Florida could look for a new plan for 2016 but what guarantees to they have that the same bait and switch won’t occur?
Is there an upshot here? You do receive notification with 60 days to figure out what to do. The notification that you’ll receive about your drug being dropped must contain, to quote from the federal regulation, “alternative drugs in the same therapeutic category.” It might seem like small consolation if the medication you’ve been using works but do not rule out a pharmaceutical alternative, probably a lesser expensive generic, IF your prescriber believes it will work just as well.
If you and your healthcare provider decide you should take the drug that was dropped and not a pharmaceutical alternative, and the costs are too high domestically, then you might consider an international online pharmacy verified by PharmacyChecker.com. Brand name drugs are often 90% lower outside the U.S. when purchased from a verified online pharmacy.
Finally, there is an appeal process that you and your healthcare provider can use if you believe your plan isn’t covering the medications you need – including ones that they drop! I’ve read that this process can be a serious nightmare. But this is a blog post unto itself and I plan on covering this topic in the weeks to come.
Tagged with: bait and switch, consumer review, formulary changes, Medicare Part D, medicaredrugplans.com
by Gabriel Levitt, President, PharmacyChecker.com and Prescription Justice | Nov 6, 2015 | Drug Importation, Drug Prices, Generic drugs, Government
Americans should know about the heat coming down against the pharmaceutical industry from certain members of Congress in an effort to combat the public health crisis of high drug prices. This week, nine lawmakers from the House of Representatives announced the formation of a new group called the Affordable Drug Pricing Task Force. Its goals are clear, to lower cost barriers to life saving medication and to demand greater transparency about drug cost decisions made by the pharmaceutical industry.
Two pertinent facts were continually raised. One, high drug prices are the No. 1 healthcare issue in America. Two, medication prices are much lower in other countries, about 50% lower in the UK.
To announce the task force, a press conference was led by Congressman Lloyd Doggett (D-TX) and included speeches by Rep. Sander Levin (D-MI), Rep. Jan Schakowsky (D-MI), Rep. Jim McDermott (D-WA), Rep. Rosa DeLauro (D-CT), Rep. Peter Welch (D-VT), Rep. Marcy Kaptur (D-OH), Rep. David Cicilline (D-RI), and Congressman Elijah Cummings (D-MD). We wrote about Rep. Cummings’ efforts a couple of weeks back as Congressman Cummings noted PharmacyChecker.com as a supporter of the Prescription Drug Affordability Act of 2015. I also want to note thank Congresswoman DeLauro for recently becoming a co-sponsor of the Personal Drug Importation Fairness Act of 2015.
The speakers have supported a variety of solutions to lowering drug prices, including allowing Medicare to negotiate drug prices with pharmaceutical companies; ending “pay-for-delay,” a practice sometimes described as payoffs by brand drug patent holders to generic drug companies to that the latter will postpone launching a lower cost generic; reforming prescription drug importation laws to make it easier to access lower cost medications from other countries; and greater oversight into pharmaceutical industry pricing practices.
Some highlighted quotes or phrases:
- “If the people are not able to afford their prescriptions that means they suffer and in some instances they die.” Rep. Cummings.
- McDermott’s take: “The pharmaceutical companies have got the Congress in the palm of their hand and they will not let us go.”
- The problem of high drug prices was referred to as an “emergency situation” by Rep. Sander Levin.
It’s no secret that I support much of this agenda. But what is needed is bipartisanship, and I’m waiting for these leaders, as part of their noble effort, to consider looking critically at the Obama administration’s record on personal drug importation and online pharmacies. Candidate Obama in 2007 supported reforming the law to make it easier for Americans to import lower cost medication. Unfortunately, in its efforts to pass the Affordable Care Act, which I supported, the Obama administration made a deal with big pharma to change course and dump drug importation legal reform in exchange for pharma’s support for Obamacare and agreement to new discounts on Medicare Part D medications through the coverage gap (the “Donut hole”).
On that final note, the Obama administration, though the Department of Health and Human Services (HHS), has announced a forum on drug prices to be held on November 20th. Maybe we’ll learn that the Obama administration’s position on prescription drug importation has returned to one more in line with most Americans. We’ll keep our fingers crossed.
(You can view the complete press conference below)
Members of the newly formed Affordable Drug Pricing Task Force will hold a press conference announcing meaningful action to combat the skyrocketing costs of pharmaceuticals. Who: Reps. Cummings, Doggett, McDermott, DeLauro, Schakowsky, and Welch.
Affordable Drug Pricing Task Force Press Conference – Nov 4, 2015
Tagged with: Affordable Drug Pricing Task Force, Congress, David Cicilline, Drug Importation, Elijah Cummings, generic drugs, Jan Schakowsky, Jim McDermott, Marcy Kaptur, Online Pharmacies, Personal Drug Importation Fairness Act, Peter Welch, Rosa DeLauro, Sander Levin, United States
by Gabriel Levitt, President, PharmacyChecker.com and Prescription Justice | Oct 30, 2015 | Drug Prices, Medicare Drug Plans
We’re two weeks into the open enrollment period of Part D Medicare Drug Plans and it is my deepest hope that if you are a Medicare enrollee then you are taking time to find the best plan. It’s not easy. Finding the right plan, however, could mean getting the medications you need to stay healthy, saving money, and avoiding lots of headaches throughout the year. Our website, MedicareDrugPlans.com, gives you basic information, such as premiums, deductibles and coverage levels, but also ratings and reviews about Part D plans that can inform you about the experiences of your peers in using the different plans. Your final search should be with the government’s website – Medicare Plan Finder – where you can find the plans that cover the medications you are already taking now and specific costs related to those plans. Below are key points about costs and coverage.
Part D Plan Costs
Plan costs have gone up this year. The deductible cap increased by 12.5%, from $320 to $360. Fifty-three percent of the plans are charging the full deductible, while the other 47% charge less. Average premiums have increased from $36.68 in 2015 to $41.46 in 2016. The lowest monthly premium is $6.80, that’s if you live in Puerto Rico and choose the Humana Preferred Rx Plan. The highest premium is $174.70, that’s if you live in Florida and choose Blue MedicareRx Option 2.
Part D Plan Choices
The overall trend of having fewer Part D plans to choose from continues this enrollment season, down to 886 this year compared to 1001 last year. Looked at historically, the declines are even more striking, as there were 1,875 plans in 2007. These numbers are the totals available in all states and U.S. territories but options are really state-based. Alaskans had only 19 plans to choose from, compared to a high of 29 in West Virginia and Pennsylvania.
Part D Plan Coverages Phases
There are four coverage phases for Part D plans: deductible, initial coverage period, the coverage gap, often referred to as the “donut hole,” and catastrophic coverage. The deductible is pretty straightforward–you pay the full cost of your medications up until that dollar amount, which can be as high as $360. During the initial coverage period, you usually pay about 25% of drug costs and the plan picks up 75% until total costs have reached $3,310. At that point you’re in the coverage gap, but you’re paying discounted prices, 45% and 58% of brand and generic drug costs, respectively. Once total costs have exceeded $7,515, you are in catastrophic coverage territory, and only have to pay 5% of your total drug costs until the next year begins.
Understanding these generalities about Part D plans is important, but the devil is in the details, which can only be understood through research. It’s not enough to just stick with the plan you have. Nine out of 10 Medicare enrollees do not change plans, and many end up with higher drug costs because they don’t. The landscape of plans changes every year; so do your research, shop around, and get the best plan for your health and wallet!
For a thorough plan analysis see Kaiser Family Foundation.
For ratings and reviews, check out www.medicaredrugplans.com.
To finalize your decision go to Medicare Plan Finder.
Tagged with: donut hole, Kaiser Family Foundation, Medicare Drug Plans, Medicare Part D, medicare plan finder, Medicare.gov, medicaredruglans.com
