by Peter J. Nebergall, PhD
This article appeared in Voice of the Diabetic, Volume 17, Number 3, Summer 2002 Edition, Published by the National Federation of the Blind. Updated April 2005.
The Problem
Several years ago, a widely-publicized international study ranked American health
care 37th in the world, principally because it was not "universal,"
or "single-payer," as in nearly all other developed countries. One
of the survey's authors observed: "Poor health is the biggest producer
of new poverty in the United States." Our doctors and hospitals may be
very good indeed, but our financial "safety-net" has holes in it --
and if you have diabetes, you've probably found a few of those holes already.
The direct medical costs of diabetes in the U.S.A. (the money we pay the doctor, the hospital, and the pharmacist) run about 44 billion dollars a year, according to the U.S. Centers for Disease Control. That works out to $4000 dollars per diabetic per year -- above and beyond our already high general health costs and fees. That's a hardship for a lot of people -- especially if you receive an hourly wage, and don't have a fantastic "benefits package."
If you're old enough or sick enough to qualify for Medicare, you'll have found the program covers a lot, but not everything. If you have private insurance, it may or may not be adequate for your needs, and the HMOs, desperate, drowning in red ink, are cutting back wherever they can. Millions of people have no prescription coverage, or no medical coverage at all. How do we pay for what we need -- now? Although we can't address "paying for the doctor" today, there are options, if you need some help paying for your diabetes medications.
Paying for Medications
Outside of Medicare, Medicaid, and private insurance, there are some alternatives
to paying list price out of pocket -- maybe more than you think. Your doctor
is probably not aware of them either. There are the private "drug discount
cards," the Medicare-approved cards, the company specific charity programs
(see PhRMA, below), and whatever new initiative the U.S. Congress finally adopts.
Private firms and "clubs" routinely offer "as seen on tv" pharmacy discount cards. Please be careful with these, as the "benefits" may be minuscule. Some of them lock you into purchasing from a very small number of suppliers; discounts "from list" can be insignificant. Too many of these "cards" are put out by people taking advantage of your confusion to line their own pockets. If you "never heard of the company," there is probably good reason.
The big drug manufacturers, like Pfizer and Eli Lilly, offer a better deal for the low-income consumer. Their "discount cards" for individuals eligible for Medicare (SSI or SSDI) who meet their income requirement (less than $18,000 individual or less than $24,000 family) and who have no other prescription drug coverage. These cards allow a user to purchase a month's supply of any of the issuer's products, for a low set fee ($12 to $15 per med per month). Naturally, a drug company's (brand-name) card will only help you with products distributed by that drug company.
Since the arrival of government-sponsored prescription discount cards in May of 2004, things have grown far more complex. Officially "temporary," the more than 70 different "Medicare-Approved" prescription drug benefit cards were complicated, confusing, and changeable. Not government-issued but government-approved, most offered discounts of "25 to 30 percent off list," but private discounters routinely sell some of these medications at 40 percent off list or more, and users who bought in to the Medicare cards, expecting to receive the prices they were getting from Wal-Mart Pharmacy or one of its competitors, could be disappointed. Plus, a user was locked into one card per year, but the drug companies could change drug prices and availabilities at any time.
Meant to be a stopgap, to "buy some time" for the Federal Government to figure out something better, the various "Medicare-approved" cards ran the gamut -- offering different coverages, different discounts, and, past the Medicare-mandated eligibility requirements, different pricing. It took a lot of time, a lot of research (many people who need such benefits don't have internet access, or the willing grandchildren available to execute the complex internet searches and comparisons necessary to choose wisely), and there was too much "by guess and by gosh." "You have to study it, if you wish to save any money with it," I wrote of the program, when it first came on line -- and the cards' study requirements have been worse than burdensome. However, all the cards were not created equal -- and there is real possibility of making a major mistake, of choosing the wrong card for your needs, and not saving yourself any money.
Individuals whose incomes were below a preset level (about $16,800 in 2004) were eligible for a $600 government credit toward medication expenses. If their incomes were higher, they could buy into a card, but would not receive the $600 benefit. But, they had to choose which card. Which one? Which card offers the best discounts on the medications you need? Which one offers the best savings for you?
PFIZER ("the Share Card")
Effective March 1, 2002, holders of this card could purchase a 30-day supply
of any listed Pfizer prescription product, for a flat fee of $15 each. For many
drugs, this was a major discount. It was certainly an example to Pfizer's competitors
and the U.S. Government. Pfizer makes both type 2 diabetes medications and other
drugs that treat common diabetes complications, and the Pfizer Share Card could
be used at many retail pharmacies.
Pfizer has replaced the Share Card with two programs: Connection to Care (for individuals with low income and need), and the "Pfriends" card. Recognizing low-income drug purchases are a hardship whether one is of Medicare age or not, Connection to Care (within its guidelines) is extremely generous, and Pfizer Pfriends is a more "adaptable" card than its competitors, less stringent in its income maximums, and not age-mandated. It is open to all, and one would hope the new Medicare prescription benefit, scheduled to arrive in 2006, might resemble these two Pfizer programs. Of course all drug company card discounts only apply to that company's products, but Pfizer's initiatives look like a great place for the government to start.
For more information, or to receive an application, telephone: 1-866-776-3700, or see the website: www.pfizerhelpfulanswers.com
ELI LILLY ("LillyAnswers Card")
Similar to the above, includes many diabetes medications. Contact Lilly at 1-800-795-4559.
The PhRMA group, for medication assistance.
The pharmaceutical industry has a tradition of providing medications free of charge to physicians whose patients might not otherwise have access to necessary medicines. Members of the Pharmaceutical Research and Manufacturers of America (PhRMA), an association of drug manufacturers, have created a directory listing each participating manufacturer, and the products that manufacturer has decided to list. Eligibility rules vary between manufacturers, and all prescription medications are not included, nor are all drug manufacturers members of PhRMA. Still, the association's patient assistance program (which does include insulin, oral diabetes medications, and cyclosporine) is a useful safety net. PhRMA's directory is in fact quite extensive.
Transfer of prescription medications is regulated by many laws. Upon approval, medications are shipped to the prescribing physician. For information, and a copy of their Directory of Prescription Drug Patient Assistance Programs, physicians should contact: PhRMA, 1100 Fifteenth Street NW, Washington DC, 20005; telephone: (202) 835-3400. Alternatively, the directory may be inspected on line, or downloaded from their website: www.phrma.org
The Cost Containment Research Institute
Located in Washington, DC, the Institute publishes a booklet titled: Free and
Low-Cost Prescription Drugs. Regularly updated, it provides an alphabetical
listing of nearly 1200 drugs available to people for free, or at very low cost
from the manufacturer. Also offered are listings of clinics and hospitals providing
free medical care, a booklet titled Top 17 Ways to Cut Your Prescription Drug
Costs, and information on drug purchases in Canada. The drug booklet costs $5,
and is available from: The Cost Containment research Institute, 4200 Wisconsin
Avenue NW, Suite 106-222, Washington, DC 20016; telephone (202) 318-0770; fax
(202) 318-0769; website: www.institutedc.org
Prescription Drug Help
If you have prescription medications, and you can't afford them, you may know
a number of manufacturers provide free medications -- but the problem is finding
the right one, and then completing the paperwork. If you qualify (low income,
no prescription coverage), The Health and Wellness Educational Center will help
you find your necessary prescription medications, and will help with the paperwork.
Contact: (205) 652-6557; e-mail: [email protected].
MEDICARE has its own consumer website: (www.medicare.gov), offering a prescription drug assistance locator program that searches online for public and private programs that offer discounted or free medications.
Where Are We Going?
The Medicare reform law that brought us the prescription drug cards in 2004
was intended to be temporary. A product of many compromises, it was and is meant
to be replaced in 2006 by something better. What will that be? I contacted several
national-level politicians, and asked, but none have returned my calls or answered
my notes.
I'm a bit surprised. I figured there wasn't a pol alive who could refuse the soapbox -- but they have kept silent, and we have to remember that for decades, while hospital charges and drug prices have rocketed, and the number of Americans whose employers do not supply health insurance approaches the total population of France, a lot of our legislators have blocked all meaningful healthcare reform, "for ideological reasons." It's going to be a nasty fight -- and that may be why these elected officials stayed silent.
However, it's time. Talk to your representatives and senators. Ask them what they want to see, as a Medicare prescription drug benefit, in 2006. Then, talk to your friends and neighbors.
Conclusion
Is it "Your money or your life?" No. It's not that bad. There are
options. If you do the legwork, if you meet the income guidelines (which are
pretty reasonable, when you do the math), there are alternatives out there.
It may take you some time, but they're out there.
What should we be doing? We should be joining the rest of the world, with a national health service, guaranteed basic access, and price controls on basic medications. Initiatives like Pfizer's are commendable, but they are stopgaps, and the companies know it. "Until the Administration, Congress, and the states design an appropriate, high-quality, long-term solution ... we are bridging the gap," says Pfizer.
Here's hoping Pfizer's competitors, and the government, quickly follow their example.