Ive written many times about how expensive medical care is here in the SF bay area and how much its cost to treat this asthmatic, this time Id like to focus more on asthma medications when you’re on Medicare.
Before I get to that, if you’re not familiar with how Medicare works, here’s a list and brief summary of the 4 Medicare programs that most people over the age of 65 and/or disabled have paid into during their working years, and therefore entitled to:
Medicare part A. Pays 100% of the cost inpatient hospitalizations, if the hospital accepts Medicare ( most do). The cost for Medicare A coverage is free to most people when they start collecting Social Security benefits.
Medicare part B. Pays 80% of the Medicare approved rate for the costs for doctor visits, outpatient labs, etc. Part B coverage is optional and costs about $145 per month in the year 2020. The premiums are usually deducted from your monthly Social Security or SSDI Benefit.
Medicare part C. Also known as Medicare Advantage Plans. Is a program that partners with various Healthcare organizations, HMOs, PPOs, like Kaiser or Blue cross one-stop shopping kind of healthcare. Essentially you’re trading your part A&B Medicare benefits in exchange for managed care plan from one of these providers. Some of these plans include prescription drug coverage and other small perks. The monthly cost depends on the plan and requires that you continue to pay your part B medicare premiums.
Medicare part D: is a government program that works with private insurance companies to help Medicare beneficiaries pay for self-administered prescription drugs through prescription drug coverage. The monthly premiums and co-pays depends on the plan you chose.
Medigap Insurance, though not part of Medicare, is special type insurance available on the open market that help pay the 20% that Medicare part B doesn’t cover, as well as the deductibles for parts A&B. If you dont have Medigap insurance, youre in the hook for the balance of those charges.
There are 6 different Medigap plans, lettered A through G. Each have different levels of coverage and are offered by various insurance companies on the open market. Though not subsidized by the government, these plans are federally regulated to make sure that each of the lettered plans is the same, regardless of which insurance company sells them. The most expensive of these are the F and G plans, because they provide the most complete coverage.For example, if you have a Medigap F plan, you will probably never see a bill because the plan covers virtually everything that Medicare doesn’t, including Hospital co-pays and the part B annual deductible.
So anyway, like millions of others who are disabled and/or over the age of 65, the bulk of my healthcare costs are paid for by the Medicare program. Of those costs, my hospitalizations are by far the most expensive, averaging about $300,000 per admission. With the exception of a $1400 co-pay, those in-patient hospitalizations are covered in full by Medicare part A. (The fees for doctor visits is covered at 80% by Medicare part B). During hospitalizations I obviously receive lots medications, and because those medications are administered by a Nurse, they are also covered at 100% by Medicare part A . But what about all the prescriptions medications one has to take everyday when not in the hospital? How much do those drugs cost and who pays for them. Unless you’re financially well off, have good insurance through an employer, or belong to a Medicare Advantage plan, you’ll probably have to rely on Medicare part D prescription coverage.
Medicare part D was originally proposed by President Bill Clinton in 1999, and then eventually by both political parties and Houses of Congress and President Bush during 2002 and 2003. The final bill was enacted as part of the Medicare Modernization Act of 2003. Prior to that you had pay for your medications out of pocket or through an employer group plan. Of course back then, medications weren’t as outrageously expensive as they are nowadays.
Not only do these Medicare Prescription plans carry a month premium, but there are also deductibles and co- pays, as well as something crazy called the “Donut Hole“, which thankfully is sort of going away in 2020. On top of that, I find it rather odd, if not downright suspicious, that most, if not all Beta Agonist inhalers, ie Albuterol, are considered tier 3 drugs or higher, by most of these part D insurance providers. Tier 3 and 4 are usually the most expensive categories for drugs. I can see paying a little more for combo inhalers like, Advair, Symbicort, Anoro,etc, but you would think that with millions of people using Albuterol, that the price would come way down. The opposite seems to be true.
As an example, at the beginning of the year my part D prescription plan, for which I pay a $30 monthly premium, charges me $371 for a 90 supply of Ventolin (which for me is 6 inhalers). That’s more than $60 per inhaler! After I meet my deductible of $230, subsequent refills drop to $141. That’s a little better, but still way more than what it would cost to buy it in just about any other country. I suppose it wouldn’t be so bad if that were the only medication I have to take. However, like most people with severe lung problems, I have several inhalers I have to take, as well as a ton of pills. It all adds up, and living on a fixed budget I sometimes find myself having to decide which drugs I can go without. Unfortunately, for most severe asthmatics there’s no middle ground. Either you find a way to get ALL of your medications or you risk ending up in the hospital and/ or possibly dying.
Pissed off and frustrated with the whole system, I did my own research. Through experimentation, trial and error, I found a few ways to save myself from ending up the poor house or going without some of my medications. Maybe these tips can help you too.
First, if possible, use a discount coupon program like Good Rx to search for pharmacies in your area that offer the lowest prices (with the coupon) for the drug or drugs you want. Federal regulations prohib using these coupons to lower your part D co-pays, but it’s completely legal to ask the pharmacy to bypass your insurance ( private insurance or Medicare) and apply the coupon discount to the regular retail cash price. Many times this price will actually be lower than the insurance price. And because you’re purchasing the prescription outside of your plan, the money spent is not applied to your plans limits. This can be a good thing, because once you exceed that limit and you’ve fallen into the ( there’s that word again) donut hole, you pay a higher price for everything until you reach your out-of pocket limit for the year.
Second, if you use a lot of Albuterol or other inhaled medications like I do, contact the drug manufacture directly. Almost all of the major drugs companies have patient assistance programs for both low income people and people who have Medicare part D coverage. As an example, Teva Pharmaceuticals who makes Albuterol, has a program where you meet the income criteria, they will provide you with free Albuterol for up to a year once you spend $600 on your prescriptions. $600 may seem like a lot, but trust me, you’ll easy exceed that in 3-4 months. For more options, check out this excellent resource on the Allergy Asthma Network website.
Third, and this has been a lifesaver for me, be aware that Medicare part B ( the one that covers doctors visits and out patient stuff), also covers certain respiratory medications, including Albuterol and Atrovent, IF they are delivered by nebulizer. They will cover unit -dose vials of Albuterol, as well as Albuterol solution ( 20 ml bottle), which you can mix with normal saline ( I buy the saline on Ebay ) The advantage of getting your nebulized meds through Medicare part B instead of Medicare part D, is because just like all other services covered under part B, nebulized medications are covered at 80% of the Medicare approved rate. Btw, The “Medicare approved rate”, simply means that Medicare will pay 80% of what it deems a fair price for a particular drug.
As you can see in my own example above. The retail or cash price ( if you paid out of pocket) for 6 boxes of Albuterol unit doses ( 180 vials) at Riteaid near where I live is $224.99, plus a $33.00 dispensing fee ( whatever the heck that is) for a total of $257.99. However, the Medicare approved rate for that drug is only $16.04 plus the $33.00 dispensing fee for a grand total of $49.40. Medicare will then pay 80% of that $49.40 leaving a balance due of only $9.81. Now, If you have a Medicap plan, they would pay that $9.81 and you would owe nothing.
You can see in the second graphic that the $9.81 was paid by my Medigap plan. I wont get into whether or not someone should have a Medigap plan, it really depends on your particular needs, but for me with of all of my hospitalizations and other things, it makes total sense.
Btw, Medicare part B will only pay for 6 boxes (180 doses) per month of Albuterol, which only lasts me about 3 weeks. To make up for that extra week, I had my doctor write a prescription for Albuterol Solution as well, which Medicare part B also covers. A 20 ml bottle of Albuterol solution is enough for appx 30-40 neb treatmentss, which for me is a little over a week’s worth. So using both forms of Albuterol, I have enough to get through the month with my nebulizer treatments and it costs me nothing.
Hope my explanations and info makes sense and helps a little.