Medicare Part D: The Biggest Rip That Ever Came Down the Pike?

I’m beginning to think that Medicare D (which supposedly covers prescription drugs) is one of the biggest scams ever to profit the insurance industry. They’ve got old people over the barrel, they don’t cover very  much, and even the cheapest Part D plan is amazingly expensive.

The deal goes like this:

You sign up with a private insurance company to get prescription drug coverage. Premiums vary by insurer, but the cheapest is about $20 a month. The average is about $30.

If you decline coverage, you can climb onboard later…but to do so, you have to pay an extra gouge — for the rest of your life! If you don’t sign up for Part D the minute you become eligible for Medicare (at the age of 65) and you need it later, you have to pay higher premiums.

The deductible is exorbitant — mine is almost $400. If, like me, you don’t take prescription drugs every day of your life, this means you end up paying out of pocket for everything. Got that? If yours is an average premium, then you’ll shell out $600 or $700 before your coverage kicks in.

If you actually do fall ill, or if you have a very expensive chronic illness such as MS or Parkinson’s, then you will eventually hit the “doughnut hole.” After the costs of your meds hit $2,970, your insurer no longer has to cover you: you get to pay everything out of pocket.

In other words, Part D insurers collect a ton of money from you, but they really don’t have to pay out much. It’s a gold mine! Thank you very much, insurance lobby and craven elected representatives.

This is the scenario from the git-go. Then, to keep from having you cost them anything at all, Part D insurers impose all sorts of restrictions on the medications you’re allowed to use. Most companies try to keep you from buying brand-name drugs — they’ll only cover generics. For most consumers, this is probably OK, but the fact is that some generics actually are different from the brand-name versions, and for some people they don’t work as well.

Now we have this: pre-approval for prescriptions!

Yes.

When I went to the doc last week to find out why my back, leg, and foot have hurt nonstop for the past eight months, I was told nothing was broken and it appeared the issue was a stubborn muscle spasm. He prescribed a muscle relaxant.

I asked him to make the prescription for a generic. He said the stuff didn’t come in a generic.

I knew my Part D crooks wouldn’t cover a nongeneric drug but figured what the hell, I’d just pay for it out of pocket.

Not quite. When I got to the pharmacy, I was told that no indeed, Part D would not cover it. The price? A hundred and five dollars…for 24 pills! Which I was supposed to take three times a day: a week’s supply.

While there, I recalled why I was unhappy with my local Safeway’s pharmacy: they’ve hired an illiterate moron as an assistant. You can’t get past her, and after she’s greeted you with “I do got the pills but…”  you realize she’s every bit as stupid as she sounds every time she opens her mouth.

I called the Mayo, asked for a different prescription, and told them to please send it to the Walgreen’s, not the Safeway pharmacy. They jumped through the hoops required for that: this involved calling the insurance company and asking what muscle relaxant they would cover. Once they knew that, they called Walgreen’s and ordered it up.

The woman I spoke with at the Mayo said the price would be about $17, so even if it wasn’t covered, I could afford it. The multisyllabic name of this drug went right past me, so I couldn’t look it up online at that moment.

Before long, Walgreen’s machine called to say there was a problem. I drove over there to see WTF, and was told Part D wouldn’t cover the stuff because it wasn’t pre-approved!

How, exactly, are you supposed to get “pre-approval” — presumably before you even go to the doctor — for a medication you don’t know you’re going to need?

I paid for this generic concoction out of pocket. Remember, this is my doctor’s third choice: the first was rejected because it was not generic. The second, a generic, was not on their “formulary” — a list of the meds they will pay for. The third is something called cyclobenzaprine.

Once at home with the spelling of this chemical in hand, I sit down to read the package insert and look it up online.

And what do I learn?

It’s contraindicated for older adults! Yes, it says right here in their handout “CAUTION IS ADVISED WHEN USING THIS  MEDICINE IN THE ELDERLY because they may be more sensitive to the effects…especially confusion, hallucinations, and fast or irregular heartbeat.” That’s their all-caps, not mine.

Think of that.

I’m here by myself, all alone. The last time I needed help late at night, my son wouldn’t answer the phone and neither would anyone else. And the medication I’ve got here is likely to cause “confusion” and “hallucinations”? And it’s the only medication that my insurer, on a policy designed for the elderly, will cover?

So I’ve spent $17 on a bottle of 24 pills that I can’t use. And BTW I still hurt from stem to stern.

I’m really very angry about this. Seventeen bucks I can sustain, but that’s not what it’s costing me. This year I’ve still ponied up $240 in premiums, almost $400 in deductibles, plus whatever amounts Part D won’t pay toward meds that are covered.

Because 2012 has been The Year from Hell in the health department, with one ailment coming right on the heels of the last for the past 18 months, I in fact burned through the deductible, along about the start of November. The last Rx I ordered indeed was…uhm…”covered”: it cost $16, of which Part D paid two dollars.

What a rip-off.

I’m beginning to suspect that if you have no chronic ailment that requires you to take medications all the time, you might be better off not to buy Part D at all. Take a look at what this guy has to say:

The trick here is to add up your TOTAL cost, including premiums, deductibles, and co-pays, and see if that’s more than you’d pay out-of-pocket for your meds.

He wrote that in 2006, when the magic number was about $2,250. He figured, at the time, that if your predictable costs for medication are under $2,250 a year, Part D may make no sense. And if you take no regular drugs at all, this “insurance” makes no sense, period.

As for the premium penalty, he pointed out (again: six years ago) that the gouge is a 1 percent increase for every month you’re not on this exorbitant scam, and at that rate it would take eight years for your premium to double.

Another writer points out that if you’re on Part D, you may end up paying more for drugs out of pocket, for no other reason than that your pharmacist has your Part D card. If you have no coverage, it’s possible to negotiate lower prices; plus big-box stores like Walmart and Costco are now offering dramatically lower prices, as are stand-alone pharmacies with “membership” plans. In addition, even though buying prescription meds from Canadian and Mexican suppliers is technically illegal, Americans are still doing it — and contrary to Big Pharma’s protestations, Canada is not exactly a Third-World country.

What happens if you get cancer and need expensive chemotherapy?

Well, you certainly could be up the creek.

Maybe.

As it develops, Medicare Part B actually does cover certain drugs: injectable prescription drugs, which is how most chemotherapy is delivered. It also covers the pill form of certain cancer drugs, as long as they also are available in injectable form. Here’s a PDF describing these quirks. And Medicare B covers a bunch of outpatient drugs, such as oral anti-nausea drugs used in connection with chemotherapy, injectable osteoporosis treatments, immunosuppressive drugs for transplant patients, and oral drugs for end-care renal disease.

If you have a heart attack or develop high blood pressure, you’re out of luck: apparently the take-’em-forever drugs needed for those ailments are not covered.

However…one could take one’s chances. You can sign up for Part D during the month-long annual open-enrollment period, and they can’t turn you down. So, the longest you’d have to wait for coverage would be 11 months. It could be the longest 11 months of your financial life, of course…but then again, maybe not. Going bare would mean taking the chance that you would not run up more than about $2,250 in drug costs over any 11-month period, a period that shrinks steadily as each month passes.

The writer who posits that Medicare is a rip best avoided by people in good health is a little suspect as a source: he presents his theory at a single-post Blogger site. On the other hand, anyone can do the math, and so presumably with some research you could prove or disprove what he says. The second post, comparing the costs of drugs bought through Part D with those purchased on one’s own, appears at something called “The Hillbilly Report,” a title that, while cute, does render its contents questionable. But there, too: it’s easy enough to confirm or de-confirm the claims for yourself.

Be that as it may, I’ve paid $240 in premiums this year plus around $400 in deductibles, and my Part D still won’t cover the meds my doctor recommends.  And not only that, the Part D insurance is arrogantly telling my doctor what he can and cannot prescribe. Had I gone bare in 2012, during a period when I’ve been down with something almost nonstop, the cost for all my meds would have come to around $420: that’s $220 less than I actually have paid for prescriptions plus the fake “coverage” this year.

Would I be better off, assuming one day I get past this endless string of back-to-back complaints, to simply self-escrow about $100 a month for prescription meds, taking a chance that the really big stuff will be covered by Medicare B? I probably could afford it, since some months I’ve paid that much (between the Part D premiums and the meds Part D didn’t even touch). That would come to $1,200 a year. If I make it through, say, another three years without being stuck on some permanent, swallow-it-for-the-rest-of-your-life nostrum, I’d have $3,600 that could be used to cover prescriptions.

It wouldn’t go far in the event of a catastrophic illness. But then…neither would I. 😉