The Cost of Enbrel and Medicare Part D

Medicare Part D has been a blessing for many senior citizens who are on a fixed income and have a limited budget to spend on prescription medications. The Medicare Part D gap in coverage for those seniors who have a lasting illness, can be tough realization. At this time of year you hear a lot of talk regarding the donut hole or coverage gap. Why is it there, what is it, and how does it work?

Medicare’s Part D cost was reduced by creating the coverage gap. Each year, a limit for Part D is determined. The annual amount in 2007 was $2400.  The yearly amount was increased in 2008 to $2510. The amount is $2700 in 2009. The total dollar amount of the prescription drugs that you receive is how the amount is determined. This includes your co-pays and what the insurance company pays. For instance, if a drug is priced at $850 and the recipient pays $150 and the insurance company pays $700, the amount that is applied toward the yearly amount is the full $850.

When you are in the donut hole, you must pay for the cost all of your drugs. While in the donut hole or coverage gap, several Medicare Part D plans will offer limited coverage for generics. The cost of most generics is so low that the benefit of having them covered by a plan is not that much of a benefit. Everyone’s situation varies so for some patients it might be worth it to have coverage for their generic drugs.

The donut hole or coverage gap can be reached in a matter of months by Medicare people with chronic illnesses which often require high priced medications for treatment. We have seen patients reach the donut hole as early as February. The whole point for the donut hole or coverage gap was to steer people to purchase less expensive pharmaceuticals when possible. That is okay for those patients who have that option but it punishes those who must take costly medications because nothing else works. For instance, for patients with rheumatoid arthritis whose health condition can only be successfully controlled by Enbrel, they can go into the coverage gap within 2 or 3 months. Halting their medicine which has potentially disabling consequences or paying for their medicine at full cost is often the only option available for these patients. About $1,500 a month is the cost of Enbrel. Very few senior citizens can actually afford that.

Qualifying for patient assistance programs can assist some lower income people. Going directly to the manufacturer can be most helpful in obtaining low or no cost prescription drugs. Contact the company and ask about their Prescription Assistance Program.  Most all drug companies offer these programs, which enable people to receive prescription medicine they need at a price they can afford.  A lengthy application co-signed by your healthcare provider is typically necessary for entry into the program. Patient Assistance Programs run by drug companies have been in existence for over 17 years. These programs are designed to assist eligible people who can’t afford their prescription medications due to limited income or other financial problems.

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. Often times several applications had to be filed with several different manufacturers in order to gain access to prescription assistance programs.

The manufacturers think that offering information via websites and toll-free numbers is essentially all that patients need to access PAPs. They just don’t understand the inability of many patients, particularly those on multiple prescription drugs from 2 or more doctors to follow through with the confusing application process. It also places an unfair burden on the physicians that are already swamped 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 prescriptions are free and if people are capable of doing it themselves they should, but for those patients that just don’t have the patience to do it themselves, the hiring of a firm to do the job is a better option than not taking the prescription drugs they need.