Jeffrey Hamilton / Getty Images
Three times a week, Tod Gervich, aged 66, injects himself with Copaxone, a prescription medication that can reduce the frequency of relapses in people with certain forms of multiple sclerosis. After living with the disease for more than 20 years, the independent licensed financial planner at Mashpee, Massachusetts, is used to managing his condition. What he can not get used to, is how Medicare co-insurance charges are putting his wallet to the test.
Unlike commercial plans that cap members' drug expenditures each year, Medicare does not impose any limits on prescription drugs in Part D, its drug benefit. As the cost of specialty drugs increases, some Medicare beneficiaries may have thousands of dollars each year in drug costs for a single drug.
Recent proposals by the Trump administration and Senator Ron Wyden, D-Ore, would solve the long-standing problem by imposing an expenditure ceiling. But it is unclear whether any of these proposals will materialize.
The introduction of the Medicare drug plan in 2006 was a boon to seniors, but the coverage was weak. One of them was what is called the donut hole. The beneficiaries of this gap intervened after accumulating a few thousand dollars in drug costs, and then paid the full cost of their drugs. Another factor was the absence of an annual ceiling on drug expenditure.
Legislative changes have progressively closed the hole in the donut so that this year's beneficiaries will no longer be faced with a coverage deficit. In a Medicare standard drug plan, beneficiaries pay 25% of the price of their branded drugs until they reach $ 5,100 in direct costs. Once patients have reached this threshold, the catastrophic portion of their coverage comes into play and their obligation drops to 5%. But that never disappears.
It's this 5% that hits hard people, like Gervich, who are taking expensive drugs.
His dose of 40 milligrams of Copaxone costs about $ 75,000 a year, according to the National Multiple Sclerosis Society. In January, Gervich paid $ 1,800 for the drug and $ 900 in February. Rebates that drug manufacturers are required to provide to Part D registrants have also been included in the reimbursable expenses. (More information about this later.) In March, he had reached the threshold of $ 5,100 which had pushed him to catastrophic coverage. For the rest of the year, he will need $ 295 a month for this drug, until the cycle starts again in January.
This $ 295 is far from Copaxone's approximate monthly price of $ 6,250 without insurance. But, combined with the $ 2,700 that he had already paid before the coming into force of his catastrophic insurance coverage, the $ 2,950 extra that he will have this year is not a small sum. And that assumes that he does not need other drugs.
"I have the impression of being financially punished for having a chronic illness," he says. He considered stopping Copaxone to save money.
His drug bill is one of the reasons why Gervich decided not to retire, he adds, adding that an annual cap on his personal expenses "would certainly help."
Medications such as Copaxone, which can alter the effects of the disease, have seen a surging trajectory soar in recent years, said Bari Talente, executive vice president of advocacy at the National Multiple Sclerosis Society. Medications that cost $ 60,000 a year five years ago now cost $ 90,000, she says. With these totals, Medicare beneficiaries "will have catastrophic coverage, whatever happens".
Medicines specializing in the treatment of multiple sclerosis, cancer, and other conditions – defined by Medicare as costing more than $ 670 per month – account for more than 20% of total Part D plan expenditures, compared to About 6% before 2010, according to a report from the Advisory Commission on Payments on Medicare, a non-partisan agency that advises Congress on the program.
According to an analysis of the Kaiser Family Foundation, just over a million Part D beneficiaries of Part D plans who have not received low-income grants have seen the cost of drugs fall short. push for catastrophic coverage, more than double the 2007 total, according to estimates.
"When the drug plan was created, 5% probably did not seem to be a big problem," said Juliette Cubanski, deputy director of the Kaiser's Medicare Policy Program. Family Foundation. "We now have expensive drugs, and many of them are covered by Part D – where previously, a lot of expensive drugs were anticancer drugs" that were administered in doctors' offices and covered by d – drugs. other parts of Medicare.
The lack of spending limit for Medicare drugs distinguishes it from other types of coverage. Under the Affordable Care Act, the maximum amount that anyone usually has to pay as they please for covered medications and other medical care for this year is $ 7,900. Plans usually pay 100% of clients' costs afterwards.
The Medicare program does not provide for an expenditure limit for Part A or Part B, which covers hospital and outpatient services respectively. However, beneficiaries may subscribe to Medigap supplementary plans, some of which pay co-insurance amounts and set spending limits. Medigap plans, however, do not cover the Part D prescription plans.
Countering the administration's proposal to impose a spending limit on prescription drugs is another proposal. this could increase the costs of medicines for many beneficiaries.
Currently, manufacturers are awarding drug manufacturers a 70% discount on branded drugs when Medicare recipients have accumulated at least $ 3,820 in drug costs and up to $ 30,000. $ 5,100 in disbursements These rebates are applied to the total costs borne by the beneficiaries, moving them more quickly towards catastrophic coverage.
According to the proposal of the administration, the discounts granted to manufacturers would no longer be treated in this way. According to the administration, this would help direct patients to less expensive generic drugs.
Nevertheless, beneficiaries should pay more to reach the catastrophic spending threshold. Thus, fewer people would likely reach the level of catastrophic coverage for which they could benefit from an expenditure cap.
"We are concerned that some people are paying more to reach the $ 5,100 threshold and the drug ceiling," said Keysha Brooks-Coley, vice president of federal affairs of the Cancer Society's Cancer Action Network.
"It's a bit of a mixed bag," says Cubanski about the proposed calculation change. "There will be savings for some people" who will reach the catastrophic phase of coverage. "But for many, the costs will be higher."
For some people, especially cancer patients taking chemotherapy pills, the lack of a cap on drug expenses in the cover of Part D may seem particularly unfair.
These advanced targeted oral chemotherapy and other drugs tend to be expensive, and Medicare beneficiaries often reach the catastrophic threshold quickly, said Brooks-Coley.
Patty Armstrong-Bolle, a Medicare patient who lives in Haslett, Michigan, takes one pill a day, Ibrance, to help control breast cancer that has spread to other parts of her body. Although the drug has allowed her to put her cancer back into remission, she may never be released from a financial obligation for the expensive drug.
Armstrong-Bolle paid $ 2,200 for the drug in January and February of last year. When she entered the catastrophic coverage of her Part D plan, the cost dropped to $ 584 a month. The husband of Armstrong-Bolle died last year and she used the money from her life insurance policy to pay her drug bills.
This year, a patient assistance program covers the first months of co-insurance. This money will be used up next month and she will have to share her share of $ 584 again.
If she were given traditional drug injections instead of taking an oral medication, her salary would be covered by Part B of the program and her co-insurance payments could be covered.
"It does not seem right," she says.
Kaiser Health News, a non-profit news service, is an independent editorial program of the Kaiser Family Foundation. Neither KHN nor KFF are affiliated with Kaiser Permanente. Michelle Andrews is on Twitter: @ mandrews110.