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PAYING FOR DIABETES

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.