Q: My new rheumatoid arthritis prescription is on the highest tier of my drug plan. Before insurance, it costs about $3,322 for 2 injections that I take every month. I just learned that instead of a co-pay like I have with my other prescriptions, I will have to pay 45% co-insurance— more than $1,495 per month. I can’t afford this for very long without exhausting my savings. I do not qualify for Medicare “Extra Help.” Is there anything I can do?
A: First here’s how your drug plan coverage works, and how much you may potentially have to pay this year assuming you have no other prescriptions. The initial Part D coverage amount you receive in 2015 including any deductible is $2,960. Once you reach that limit, which would occur the second time you fill your prescription, you hit the Part D coverage gap. During this gap period you would pay 50% of the cost of your arthritis medicine ($1,661) up to $3,720, which you would hit by your fifth refill. Once you have spent a total of $6,680 out-of-pocket your plan’s catastrophic coverage kicks in and you would pay a 5% co-insurance — about $166 per month for the next 6 months. Altogether you would pay roughly $7,676 for just that one prescription alone — that’s something few people can afford for very long.
You may want to find out if there’s a pharmacy assistance program for the drug you take. The programs are available through public service organizations, foundations and drug companies and can assist with medications for specific prescriptions or diseases. A listing by drug can be found on Medicare’s website at http://www.medicare.gov/pharmaceutical-assistance-program/#.
Each program has different eligibility requirements, and each has its own application to fill out. You may want to seek help with applications, especially if you don’t have access to the Internet. The place to start is through your State Health Insurance Assistance Program (SHIP) counselors. You can receive free one-on-one counseling about your Part D coverage and to learn about pharmaceutical assistance programs. Many of the programs operate through local Area Agencies on Aging or Senior Services Departments. For help finding services in your area call the Eldercare Locator at 1-800-677-1116.