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Author Topic: Medicare Part D - Gap in Coverage  (Read 2624 times)

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Offline HarrynAlabama

  • member
  • Posts: 2
Medicare Part D - Gap in Coverage
« on: October 27, 2006, 12:49:07 PM »
Medicare Part D covers prescription medications that are on the formulary for the first $2250.00 with the patient having to pay a copayment based on the tier or band in which the drug falls into.

Once Medicare pays $2250.00 in prescription cost for a member/consumer then the member/consumer is responsible for paying 100% of the cost of prescription medications until the consumer/member pays out $1350 or total prescriptions reach $3600.

After the member/consumer has paid the $1350 out of their pocket then Medicare Part D picks up the remaining prescription medication cost at a reduced copayment for the remainder of the calender year and then the process repeats itself every January.

OK, now I have presented to yo how Medicare Part D coverage works let me discuss my personal situation with this  forum as I am concerned and would appreciate learning how others in similar situations have dealt with this.  I hope this is NOT too personal or too much detail but I cannot think of any other way to discuss this concern of mine.

I am 46 years old in the third world country of Alabama where the ASO does not have any funds to help clients instead it seems they make payroll faithfully. I have HIV positive since 2000 and I have several other medical conditions to name a few are crohn's and severe depression and that is the short list of problems.

I am medically disabled due to my illnesses and my income comes from Social Security Disability, Long Term Disability from my former employer, and I work three part time jobs just to make ends meet and they still do NOT.

My medications run over $1700.00 per month many of which I am just living without. I am ordering my HIV medications from India (generic) as I cannot afford the HIV medications here in the USA. I am NOT taking anything for Crohn's or severe depression now as I cannot afford it.

My question to this group or anyone is, if you make too much to qualify for Medicaid or additional assistance from Medicare how do you afford your medications and what do you do? I am at a loss a real loss.

I am finding myself getting more deeply depressed and feel like I am in a no win situation.

I have requested assistance from my local ASO, a charitable pharmacy and the drug manufacturers all of which state my income is too high to qualify.  Sure I am lucky to have a decent income but I am living NOT in luxury I am living without the necessities.  When I figure in Rent, utilities, meds from India I do not have an extra penny. I don't know how I could ever afford all the medications I should be taking.

I am looking forward to hearing from any of you regarding this situation and how you are coping with it.
  
Thanks for your time and God Bless,

Harry N Alabama





Offline Miss Philicia

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Re: Medicare Part D - Gap in Coverage
« Reply #1 on: October 27, 2006, 01:47:57 PM »
Here in Pennsylvania if you previously had all your prescriptions covered under ADAP, once you enrolled for Med-D this year the donut hole you refer to is still paid under ADAP, as are all co-pays.   I don't know all the intracacies of ADAP for different states but I would assume that Alabama is not fully funding their program.  I think both PA and NY (where I previously lived) supplement their ADAP federal funds with state funds and that's how they offer such full coverage.

While I realize that the cost of living in Alabama is lower than NY or PA I'm sure you're actually shelling out more in the final analysis.  Have you contemplated moving to a state where the coverage is better?  I'm pretty much in the same situation as you: on SSD, not welfare/Medicaid and use those funds for rent, utilities and basic living expenses.  My income is very tight but I make it, but only because my state's ADAP coverage is pretty much 100%.  I only pay for one medication that's not on the ADAP formulary and that only comes to around $35/month.
"Iíve slept with enough men to know that Iím not gay"

Offline HarrynAlabama

  • member
  • Posts: 2
Re: Medicare Part D - Gap in Coverage
« Reply #2 on: October 27, 2006, 01:59:09 PM »
Thanks for your reply - I would consider moving if my partners parents were not elderly. We need to stay around and watch after them.

Offline David84

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  • Posts: 34
Re: Medicare Part D - Gap in Coverage
« Reply #3 on: November 02, 2006, 03:08:13 PM »
Here in Michigan its the same as Philly. ADAP picks up the difference that Medicare D doesnt. I have been very forturnate this year and last by not having to shell out big bucks. I was just reading in another post about assistance. I will go back to see if I can find it.

David


Found it!! Does it apply in this situation? I don't know, but its worth a look...

The Partnership for Prescription Assistance (toll-free, 1-888-4PPANOW or www.pparx.org) is the only source that provides a single point of access to the more than 475 patient assistance programs, which include more than 180 programs offered by the pharmaceutical industry. The PPA educational effort is supported by America 's pharmaceutical research companies working with doctors, pharmacists, health care providers, patient advocacy organizations and community groups. More than 70 major national organizations, including the American Academy of Family Physicians, the National Urban League, United Way of America , Easter Seals and the National Alliance for Hispanic Health, are involved in the campaign. PPA now has more than 1,200 local and state partners located throughout America as well.

"Millions of patients are already receiving free or nearly free drugs from these programs, but it is clear that millions of other Americans from all over the country -- in cities and rural areas alike -- are not taking advantage of the help that is available to them," said national spokesman Montel Williams.  "The PPA is a concerted and effective effort to reach those who still need help. And I'm going to do everything I can to get the word out. As a patient who must cope every day with the effects of multiple sclerosis, I understand only too well the importance of having access to the medicine you need."
« Last Edit: November 02, 2006, 03:15:30 PM by David84 »

Offline dgls44

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  • Posts: 69
!
« Reply #4 on: November 03, 2006, 12:07:37 AM »
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« Last Edit: December 24, 2006, 12:20:27 AM by dgls44 »

Offline gerry

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  • Joined AM Feb 2003
Re: Medicare Part D - Gap in Coverage
« Reply #5 on: November 05, 2006, 02:10:35 PM »
Harry:

This is one of the most basic flaws in the Medicare standard prescription coverage program.  For people with very high prescription drug costs such as yourself who do not qualify for "extra help" from Medicare, and also have a very restrictive ADAP wrap-around coverage, you get stuck with a donut hole worth over $1K that hits very early in the year before catastrophic coverage begins at 95% coverage by the drug plan.  Unfortunately, there is very little alternatives in your situation.  To make matters worse, and one thing you need to investigate also, if you get your prescriptions overseas, that may not exactly count as true-out-of-pocket-expense (TROOP) that your plan might recognize.  I would urge you to check with your plan about this.  If the drugs you are purchasing from India does not qualify under TROOP, that means you would not reach the catastrophic coverage as far as the plan is concerned irrespective of how much you have been paying for these meds.  It really, really sucks.  I feel for your predicament.

Gerry

Offline SirPrize

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Re: Medicare Part D - Gap in Coverage
« Reply #6 on: November 05, 2006, 03:20:44 PM »
One option that may be viable for you is that Wal-Mart includes Alabama in their $4 pharmacy program.  The program offers a 30 day supply of commonly prescribed generic medications for $4 per prescription.  To view the list of medications that qualify; go to their website, click on pharmacy, and view the formulary (antidepressants and anti-inflammatory are both listed).
Due to current economic conditions, the light at the end of the tunnel has been temporarily turned off!

Offline dgls44

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!
« Reply #7 on: November 05, 2006, 07:42:37 PM »
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« Last Edit: December 24, 2006, 12:25:17 AM by dgls44 »

Offline dgls44

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!
« Reply #8 on: November 06, 2006, 02:08:52 PM »
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« Last Edit: December 24, 2006, 12:25:47 AM by dgls44 »

Offline gerry

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  • Joined AM Feb 2003
Re: Medicare Part D - Gap in Coverage
« Reply #9 on: November 06, 2006, 10:23:21 PM »
When you look at what's written in the SierraRx formulary, it still makes reference to a coverage gap, just like other standard Medicare part D plans.  So I'm not exactly sure that this plan does away with the donut hole.  It did not look like that to me (especially at that premium level).  Here's the link (it's on page 2):
http://www.sierrahealthandlife.com/documents/sierrarx/SierraRxFormulary1205.pdf

Offline dgls44

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!
« Reply #10 on: November 07, 2006, 12:56:41 AM »
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« Last Edit: December 24, 2006, 01:00:57 AM by dgls44 »

Offline clarke

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  • Posts: 169
Re: Medicare Part D - Gap in Coverage
« Reply #11 on: November 09, 2006, 04:32:26 PM »
Humana put me on catostrophic coverage in February of this year.  Also, MADAP (Maryland AIDS Drug Assistance Program) pays the premium.  So we pay very little (a $5.00 co-pay) once in awhile.  We were extremely fortunate to have gotten on the program here.

We have freinds in Tennessee who most of the time have no clue where their meds are coming from, much less the next meal.  We got out of that State just in time, as they dumped many people from the State health care.

I'm also concerned about you getting your meds from India.  They might be cheaper, it's just there's a lot of "evidence" the quality can be compromised, and has been compromised in the past.

 


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