A Tip for Medicare Part D Users (Prescription Coverage)

Perhaps it seems a little out of character for me to comment on an issue like Medicare Part D. However, my soul is vexed when I hear misinformation and see elderly folks having difficulties with their medication because of shortcomings in the program and unhelpful pharmacies. My mother-in-law was in this very predicament and it took me some time to sort through it.

Medicare Part D provides a senior the ability to pay a (usually) small copay of $7 for a prescription medication. The insurance company picks up the remainder of the cost. However, this does not always work out so neatly. There are several tiers of medication, such as generics and common non-generics and "rare" medicines. These are not always provided at the $7 copay level. Furthermore, there is what is called the "coverage gap" or, in more picturesque terms, the "donut hole." After the insurance company pays so much, say $2000, then you are responsible for 100% of your medication cost until the coverage gap ends, at which time "catastrophic" coverage kicks in and the insurance helps you again.

The problem is that your elderly friend or relative may not be aware of just what the pharmacy is charging for a particular medication-so that you pay the $7 happily along, but the pharmacy could be eating up your coverage until, before you know it, you are in the coverage gap. This problem is further exacerbated by misinformation and incomplete information offered in pamphlets and advertising.

For instance, a pamphlet on the subject provided by the makers of Prilosec OTC (a heartburn medication) say this: "While generic prescription medications are often less expensive than brand name prescription medications, the full Medicare cost of a generic prescription medication still counts toward the total limit covered by Medicare Part D." Your elderly friend gets the impression that buying generics is a bad idea. Rather, over-the-counter medications are the best--and thus he or she would be induced to select Prilosec OTC instead of, say, the generic Ranitidine (Zantac) even though the latter may work just as well and be covered by Medicare Part D.

Worse yet, if you are in the Detroit area, you may have heard the Walgreen's radio commercial in which they claim that Medicare Part D eliminates price shopping, since all prescriptions are the same price everywhere. This smacks of a socialized approach to medicine, for one thing. But beyond that, it is simply not true. If Walgreen's charges $50 for a medication (and you pay $7), while CVS charges $40 for the same medicine (and you pay $7), your would arrive in the coverage gap much sooner with Walgreen's. This is a real problem for seniors who have complex health issues and who take many medications every day.

The solution that I found most helpful was to switch pharmacies and use generics as much as possible. We use the Kroger Pharmacy, and could just as well use the Walmart Pharmacy, because of their $4 generic programs. What this means is that we pay $4 for a generic for a month (or $10 for a three-month supply). Not only is the copay lower ($4 compared to $7), but Medicare Part D pays NOTHING and so you avoid the donut hole much longer than if your pharmacy is charging up your Part D account!

Here's a concrete example: For 90 tablets of Warfarin (Coumadin) at 3mg per tablet, we presently pay $10 at Kroger (this is a 3-month prescription). Medicare Part D does not have to pay a penny. However, before I figured all this out, we were using a pharmacy that charged $60.39 for the same number of pills--except that they were 1mg per tablet!!! Insurance allowed $41.63 instead of the higher amount; but after the $7 copay, insurance still had to pay $34.63. What a huge waste to the American taxpayer--the amount wasted is over three times the total cost of the prescription! Unfortunately, this scenario must be replaying millions of times over throughout the United States.

Another advantage is that you don't have to abide by some of the insurance companies silly rules since you are paying out of pocket. For instance, you might have heard, "You cannot fill this prescription because it is too soon after you refilled it before." But if you have changed dosages or just don't want to run to the store as often, and you are paying cash, you just say, "Look, I'm paying cash for this. Don't put it toward my Medicare Part D."

An interesting side note to this is that the market has produced a solution far superior to that of Medicare Part D. Kroger and Walmart are doing more to save senior's on their meds than the federal government!

I hope this will be helpful to someone out there. We learned the hard way--four months in the donut hole with some very expensive medications.