Wednesday, December 23, 2009

Part D discounts not always getting applied correctly for people in "doughnut hole"


People using Medicare Part D, or particularly caregivers looking after parents using Part D, should be aware that new medications need to be handled carefully. It seems that sometimes the private insurance carriers (like UHC with AARP) don’t get word on the new medication automatically, and pharmacies may greatly overcharge the patients.

Part D beneficiaries must pay for their own medications while in the “coverage gap” or “doughnut hole” which in 2009 was $2700 to $4350. But the discounted prices for the medications, negotiated by the carrier, should still apply, even when the beneficiary is covering the cost. The negotiated discount on some new medications (which can list for several hundred dollars for 30 pills for anti-cancer drugs or anti-Alzheimers drugs, for example) can be considerable. Pharmaceuticals holding patents on new drugs are charging very high list prices, and only competition or negotiation by large insurance companies or exchanges (under health care reform) can bring prices down. Likewise, older medications with several manufacturers (like atenolol) tend to be very inexpensive because of competition.

There seem to be some issues with the information flow (that is, the I.T. systems) between the insurance carriers, the pharmacies, and the prescribing providers. I’ll look into this more and report on what is really going on soon.

Picture: a miniature "Luxor" (not in Vegas).

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