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Question.
My
health insurance has just notified me that they are changing my benefits
with regards to paying for prescribed medications. Basically the plan
will now only pay for generic medications; therefore, for all trade name
medications that have no generic equivalent, I will now have to pay for.
What makes this irritating is that two of my current medications have
no known generic equivalent. What can I do? I am on a fixed income and
the cost of my health insurance alone has sky rocketed. And now adding
on the cost of medications, that used to be paid for, will create an extreme
financial burden.
LF Los Osos
Answer.
Health
insurance, that is what is provided as coverage and collapsing managed
care in our country, is the proverbial Gordian Knot of today's society.
Providing an effective and efficient Medicare drug benefit will be a hot
political issue with far-reaching financial and social implications for
years to come according to a recent article appearing in Drug Topics..
In every situation there are exceptions. I am sure that there are going
to be exceptions allowed by your insurance company. Unfortunately the
health consumer is being asked to become more involved if they want to
receive the benefits of the insurance. I am also sure that you insurance
company is well aware that there may be no generic substitute for certain
medications and the management of specific disease processes. It is likely
that your insurance company made these changes to get both the patients
and their physicians to look at what is being prescribed and see if there
could not be an equally as effective generic medication. Such changes
would reduce costs and benefit policy holders and the insurance company.
I would suggest you contact the insurance company to determine what you
physician would have to do to support the continued use of your vital
prescription medications that are not available in a generic format. It
is possible that your physician could write a letter to the health insurance
carrier detailing previous trials of other, generically available medications
and the, I presume, failed results of these trials. This would justify
why s/he did place you on your current medications. Perhaps the carrier
has an exclusion clause for medical necessities?
Another approach you might want to consider is to work with your local
pharmacy to see if you are eligible for free medication from the actual
manufacturer of the agents in question. Yes, that is right. Free medication!
Nearly every major manufacturer of medications has a patient assisted
program (PAP) to provide free medication to patients with a medical need
whose income falls below a certain income threshold. And believe me, some
of these income thresholds are high for expensive medications. Other threshold
levels are very low and few would qualify for company assistance.
The same Drug Topics article referred to earlier suggests that these programs
could be used as the foundation for universal Rx benefits for seniors
and the working poor. Not a bad idea as the companies get tax credits
equal to twice the costs associated with the actual manufacturing costs
of these medications.
You can learn more about these company sponsored PAP's by writing to the
Pharmaceutical Research and Manufacturers of America at 1100 15th Street,
N.W., Washington, D.C. 20005. If you have a computer there are several
helpful Internet sites that may provide you with help. They are: www.indicare.com,
www.phrma.org, www.needymeds.com
and www.familyvillage.wisc.org
(If you are reading this material on the RxReview web site you can simply
click the link and you will be directed to these sites) Finally, if you
want, your pharmacist can email the author of the Drug Topics Article
for more information. His email address is PeterMCiano@yahoo.com.
He is a registered pharmacist who works for a healthcare consulting firm
in Morristown, N.J.
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