You may be eligible for outside help in paying for your prescriptions; the key is knowing where to look for aid.You now know the various ways you can work with your doctor and pharmacist to lower your prescription costs safely. If you are still struggling to cope with your rising drug bill, be aware that there are some programs available that might afford you some financial relief.
Effective since January 2006, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 -- and specifically a provision under the Act known as Medicare Part D -- provides for outpatient prescription drug insurance coverage to those entitled to Medicare Part A or enrolled in Medicare Part B. Previously, those Medicare participants were limited to drug coverage that related to a physician's services, such as the administration of chemotherapy drugs, or that were delivered in an institutional setting, such as a hospital or skilled nursing facility. Participants enrolled in Medicare Advantage (formerly known as Medicare Part C) had access, and continue to have access, to outpatient prescription drug coverage through their selected private health plans.
Medicare participants who enroll in Part D must select from stand-alone drug plans administered by private companies. Each plan has a different premium, deductible, copayment, and Medicare-approved formulary. The total out-of-pocket costs for participants will vary depending on the plan chosen and the number of drugs purchased, as well as how expensive the specific drugs are.
In 2006, participants will on average pay a $25 monthly premium and a yearly deductible not exceeding $250. After reaching the deductible, Medicare will pay 75 percent of total drug costs between the deductible and $2,250. Under most plans, participants will be responsible for all medication costs above $2,250, up to a maximum of $5,850.
Once costs reach $5,850 -- referred to as the catastrophic limit -- Medicare will kick back in and pay 95 percent of medication costs. The gap in prescription drug coverage between $2,250 and the catastrophic limit of $5,850 is known as the "doughnut hole." When drug costs fall within the "doughnut hole," participants will pay 100 percent of those costs. This amounts to $3,600 in out-of-pocket expenses.
Some prescription drug plans may offer coverage during the "doughnut hole" gap. Even if yours does not, you should still bring your prescription drug plan card with you to the pharmacy when you are in the gap, because you may be eligible for other drug discounts on your medications. Additional assistance will also be available for people who have low incomes and limited assets.
Although Medicare Part D provides much-needed access to prescription drugs for many consumers, it comes at a hefty price. The Congressional Budget Office estimates that Medicare Part D will cost nearly $33 billion in 2006, increasing to $140 billion by 2015. Costs for Medicare Part D participants will increase as well. In 2007, the maximum yearly deductible will be increased to $265, and the catastrophic limit will increase (the exact amount has not yet been determined), which means that the "doughnut hole" coverage gap will increase and out-of-pocket expenses will be higher.
Some consumer advocacy groups fear there may be an additional, less obvious cost related to the "doughnut hole" gap in Medicare Part D. They are concerned that some patients may simply stop taking their medications while they are in the gap, potentially leading to an increase in emergency room and physician office visits (not to mention a rise in complications that could conceivably cost lives as well as money).For more details about the new Medicare prescription drug benefit, go to the Medicare Web site at www.medicare.gov.
Medicaid may also be a source of assistance for you. You can determine if you are eligible for Medicaid by contacting your state's Medicaid office. Many state plans provide prescription drug benefits. In addition, if you served in the military, you may be eligible for Veteran's Administration benefits, including prescription drug coverage.
Some drugmakers have set up drug assistance and/or discount card programs for low- and moderate-income consumers, especially seniors.
The Pharmaceutical Research and Manufacturers of America (PhRMA) and 46 of its member companies created the Partnership for Prescription Assistance (PPA), which provides access to more than 475 private and public patient assistance programs. To search for prescription drug assistance programs in both English and Spanish, visit PPA at www.pparx.org.
You, your health care provider, or your caretaker will have to fill out a basic online questionnaire that guides you to programs that may provide you with discounts or financial assistance in obtaining your particular medicines. According to PhRMA, in 2004, millions of patients received an estimated 22 million donated prescriptions with a value of more than $4 billion. This represents an increase over the 18 million prescriptions and $3.4 billion worth of prescription drugs donated in 2003.
Another source of useful information for seniors is the Web site of senior advocacy group AARP, at www.aarp.org. Click on the link for the AARP Bulletin and then the link to pharmacy assistance programs. This section of the site provides a useful listing of state-sponsored and manufacturer discount programs, discount cards, discount pharmacies, and other sources of prescription drug assistance.
Investigational Drug Opportunities
Participating in an investigational drug study may be a way of getting your medicines for free, at least for a while, but the situation has to be the right one. If you are interested in exploring this option, you must discuss it with your doctor. Your doctor may be able to identify for you any clinical trials of the drug you need.
Conversely, you may be able to find information on available trials by contacting or checking the Web site of the National Institutes of Health (www.clinicaltrials.gov) or a patient-support program devoted to your medical condition (for example, the Alzheimer's Association). If you are the one hunting down open clinical trials, however, you still need to discuss this option thoroughly with your physician, who knows the specifics of your condition and your medical history.
As an example, a cancer patient's doctor might suggest participation in a clinical trial as one treatment option, or the patient or a family member might ask the doctor about clinical trials of new drugs available for treatment of the patient's specific type of cancer. To learn about new cancer drugs being tested in clinical trials, the doctor and/or patient can check the National Cancer Institute (NCI) PDQ database. This database contains information on a large number of ongoing studies, as well as information on cancer treatment and prevention. Individuals can receive guidance on using this database via NCI's cancer.gov Web site (see Finding Clinical Trials), or they can call the NCI's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237). Information specialists there can search the database and provide a list of trials.
There are some potential downsides to receiving an investigational drug. The purpose of the investigation is usually to determine if the drug is better than standard therapy for treating a disease, and there is always the chance that a patient who receives an investigational drug will not benefit from it. Side effects (both long and short term) from the drug may be unknown and may be more likely to occur before a drug is approved, especially if the drug is in the early phases of testing. Finally, although the drug is usually provided free of charge, there may be other costs associated with the treatment that may or may not be covered. Patients should check with their insurer about coverage of these costs prior to beginning treatment.
Reducing your prescription drug costs is no small task. There are many factors to consider, but there is help available. By consulting with your doctor, your pharmacist, and other agencies, you can lower your prescription drug bill.
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This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. Neither the Editors of Consumer Guide (R), Publications International, Ltd., the author nor publisher take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this information. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider. Before undertaking any course of treatment, the reader must seek the advice of their physician or other health care provider.