Medicare -- A Journey Through the Swamp
by nomoreapathy, Sat Jan 28, 2006 at 12:22:23 PM EST
I took my first tentative steps in trying to figure out the Medicare Part D Prescription Drug Program (PDP) in the last three weeks and I'm no wiser than when I started. Yes, I found an attractive plan, but no, it doesn't cover the drug I am not getting currently but have been advised by the rheumatologist that I need (list price $1,037 for 6 shots). The same drug is obtainable from Canada for $635. This therapy is reputed to have dramatic results in the treatment of rheumatoid arthritis. The therapy may continue for as long as six months.
My choices then become paying a higher monthly premium and having that amount deducted from my social security check or waiting until the rheumo gets so bad my hands don't function at all or a) hold off till Congress fixes something or resigning myself to seeing my savings, on which I depend, wiped out.
Consider: I am currently spending on average $227 a month for 2 brand name drugs and two generics. As an aside, there is a $60 difference in the price of one generic from Costco and one of the other major pharmacies. Costco has the cheaper one.
Let's do the math. The higher priced premium which covers the drug in question (Enbrel) will cost around $30 a month. Annual costs for the remainder of this year (10 mos.):
$2270 Present drugs
$4148 Needed drug (4 treatments - hopefully)
Out of the above total I can deduct $4813.50 as Medicare's 75% share leaving me with a cost of $904.50 as co-pay. Pretty good deal, huh? Oh wait! The GAP!!!
The Medicare gap, according to the brochure from the insurance company whose plan I'm studying states that after $2.250 TOTAL costs, mine and theirs, I will then have to pay all costs until I reach $3,600 of out-of-pocket expenses. Let's see. My $904.50 plus an additional $2,695.50 making my $3,600. Oh wait. The $300 I paid in premiums: $3,900. But if I deduct $3,900 from $5,718 I've still saved $1,818. Right? Well, I have to factor in that I'm paying $60 extra for 5 hits of the overpriced generic at their "preferred" pharmacy so I have to deduct an additional $300 -- now down to $1,518 in savings. The high-priced, top tier injectible requires at least 16 office visits since I'm not allowed to give the injections to myself. Forgot about that. $9 average co-pay -- another $144 to deduct. I hesitate to mention that it's a 16-mile round trip to the doctor's office, but who's counting.
Oh wait. I forgot to figure in just how much the insurance company is paying for all this. It would seem that the premium is all they get -- since of the first $2,250 I paid 25% and Medicare reimbursed them for the rest. Someone else will have to determine how they figure in this. My investigation seems to indicate that big insurance companies like Humana have only one preferred supplier -- Wal-Mart. Hmm. Given Wal-Mart's power to reduce supplier costs, might there be a little negoshiatin' going on here? You don't suppose that insurance companies are paying less for the drugs than they are billing Medicare for? Nah! Couldn't be.
Since the legislation setting this miscarriage up forbids the government to negotiate drug prices, wouldn't it make sense to change this one item in the law first, and then add a single-payer system? The burden of paperwork is on doctors and the drug stores, and the only ones making out like bandits on this thing are insurance companies and the big pharmaceuticals. Maybe I should take my $1374 in savings and plunge into the swamp. Jeez, an incompetent lobbyist makes more than that in less time than it took me to type this.