Medicare prescription co-pays

[Almost2late]

From Ask Dr. Joel: Questions about HIV and AIDS

Anonymous Asked

Question

Canadian reader here, I just saw the post were the reader talked about how his new monthly insurance makes Odefsey co-pay $850 a month. Is this common in the United States? How does anyone afford treatment there?!

Answer

We have a seriously screwed up healthcare system here in the U.S… if you can even call  it a “system.” Medicare didn’t used to provide prescription benefits. George W. Bush fixed that, but in doing so he prevented Medicare from negotiating drug prices with the pharmaceutical industry. Instead, there were built-in “donut holes”–coverage gaps during which you’re responsible for your own drug costs.  At the same time, the patient and copay assistance programs offered by drug companies can’t be used if you’re covered by Medicare or Medicaid.  Thus, Medicare patients often have very high out-of-pocket medication costs, even though they have fairly broad coverage for other healthcare expenses.

Our system got better under Obama because the number of uninsured declined and the extent of covered services improved.  But because we don’t have a single payer system or a government option open to everyone, and because states can choose not to expand Medicaid,  we still have an incomplete, patched-together system, and Trump and the Republicans are doing their best to dismantle the Obamacare gains.

Americans are terrified of “government control of healthcare” or anything smacking of “socialism”…until they turn 65, when they’re thrilled to get their Medicare card. Just don’t suggest we should offer the same benefits to younger people. That, they say, would be socialism (making us too much like our more sensible neighbor to the north).

http://hivforum.tumblr.com/post/160059883601/canadian-reader-here-i-just-saw-the-post-were

Is anyone here on medicare? Are there other ways to pay this insane co-pay? bc I don't think I will be able to afford this when it's time for me.

[garyt92264]

I am looking at Medicare in the next couple of months.   I have been on a large number of med regimens since I was diagnosed in 1985.  The past years have been truvada/descovy, Lexiva, Norvir and seems to work well.  In researching the various Medicare options, it is shocking to see what my perscription drug costs will be once Medicare kicks in.....they will be, simply put, unaffordable.  I currently have private insurance, which with copay assist cards, results in 0$ copay each month.  My financial assets, are too much to qualify for any Medicaid type program, yet not enough to afford what I will be charged.  In conversations with my MD, he suggested that I look into switching to other meds, some of which are now treated as generics.  Has any one else gone this route??  Any feedback on how to deal with the high copay costs of meds on Medicare??  I have thought about stopping any sort of med treatment all together.  Thanks for any input

[3DollarBill]

Have you checked with insurance/HMO companies offering Medicare plans?  Also check to see if your state has an assistance program for med co-pays and related expenses.  If this sorry state has such a program I'd be amazed if the other 49 don't.  This year the minimum annual income limit was raised to 4X the poverty rate so I easily qualify.  I hope you have such assistance available. 

I've been with Peoples Health for 12 years and they get my Medicare premium.   I can only use doctors in my network but there are enough choices for me.  Before you select a plan check their "provider listings" for doctors you currently see or ask your primary doc/docs what plans he accepts.  Generally Medicare recipients aren't as limited as Medicaid recipients in choices since Medicare pays more for services.  My HIV doctor and psychiatrist both accept the plan I'm on.

You should be able to see a current formulary before going with a plan so you'll know what you might have to pay for meds if assistance isn't available.  In 2011 I racked up a lot of credit card debt when I fell into the "donut hole" the first time.  My HIV med co-pay went from $50 to $450.  Before then co-pays had never been higher than $50 and I wasn't aware of the bureaucratic changes effecting the increase. 

Since 2012 I've received med co-pay assistance from the state and now pay $0 for all of my prescriptions.  I was taking AZT/3TC/abacavir sulfate (generic Trizivir) until January, 2015 when the co-pay went up to $500, my state assistance hadn't kicked in since they had a backlog, and I was late getting my application in (I thought I could afford $50 for a month or so ... not $500).   I tried to find the generic online overseas but found only the 3 separate drugs.  I got Viraday (generic Atripla) for about $150.  Here's the punchline -- the plan's co-pay for Atripla was $50.  Why a generic cost more than a brand name is still a mystery.  I'm now on Odefsey with the same $50 co-pay until the donut hole hits, which is when state assistance really saves my life. 

Don't know if any of that is helpful but hope so.  Feel free to ask for clarifications.