Medicare Part D and the High Cost of Enbrel

For many senior citizens who have Medicare Part D, a fixed income makes it very difficult to afford their prescription drugs. For those patients who have a lasting illness, it can be very difficult when they hit the Medicare Part D donut hole. At this time of year you hear a lot of talk regarding the donut hole or coverage gap. What is it, why is it there, and how does it work?

To reduce the cost of Medicare’s Part D coverage, the coverage gap was created. The yearly limit for Part D is determined each year. $2400 was the 2007 annual limit.  $2510 is what the yearly limit was increased to in 2008. The amount is $2700 in 2009. The amount is calculated on the total costs of the drugs that you receive. This includes your co-pays and what the insurance company pays. For example, if a prescription medication is priced at $1550 and the insurance company pays $1500 and the recipient pays $50, the amount that goes towards the annual limit is the entire $1550.

You are responsible for all of your prescription medication during the time you are in the coverage gap. There are many Medicare part D plans that offer coverage for generic drugs when you are in the donut hole. The cost of most generic drugs is so low that the benefit of having them covered by a Part D plan isn’t that great of a benefit. For some it could be worth it to have prescription coverage for generics, everyone’s situation varies.

For Medicare patients with chronic health conditions which often require costly medicine for treatment, the donut hole or coverage gap can be reached in a matter of weeks. Reaching the donut hole or coverage gap as soon as February is not uncommon. The reason for the coverage gap was to encourage people to purchase cheaper pharmaceutical products when possible. This punishes those patients who must use high priced prescriptions because nothing else works. Patients whose rheumatoid arthritis is successfully controlled by Enbrel can reach the donut hole or coverage gap within two to three months because of the high price. The option at this point is to pay for the medication at full price for several months until the catastrophic coverage portion applies or suffer the potentially disabling consequences of stopping their prescription drug. The cost of Enbrel is roughly $1500 per month. Few senior citizens can actually afford that.

Patient assistance programs can and will help those applicants who qualify. The best way to get low cost or free medicine is to talk to the manufacturer. Call the company and ask about their Prescription Assistance Program.  Almost all drug manufacturers offer these programs, which enable patients to receive prescription drugs they need at a price they can afford.  You and your physician will need to complete an application. Patient Assistance Programs run by pharmaceutical companies have been in existence for over 18 years. These programs are designed to assist eligible patients who can’t afford their prescription medications due to limited income or other financial hardships.

Drug companies did not want their low income patients to be forced to make a choice between paying for life saving prescriptions or for paying for rent or groceries.  As a result, patient assistance programs came into being as part of the company’s philanthropic efforts. Until relatively recently, very few people knew about the existence of these programs or could follow the complicated application process that was necessary for participation. In many cases multiple applications had to be filed with several different drug companies in order to gain access to assistance programs.

The manufacturers think that offering information on their websites and toll-free numbers is all that patients need to access PAPs. They don’t understand the inability of many people, particularly those on multiple prescriptions from 2 or more physicians to follow through with the lengthy application process. It also places an unfair burden on the doctors that are already overburdened with paperwork. Fortunately there are companies that will perform the task for patients for a fee. These prescription assistance companies will generally coordinate the process from beginning to end. Of course the prescription assistance is free and if patients are capable of doing it themselves they should, but for those people that just do not have the capacity to do it themselves, the hiring of a company to do the job is a better option than not taking the prescription medicine they need.