What should you do if your prescription drug needs change because of health deterioration? Shopping for a new Medicare Part D prescription drug plan during the annual Open Enrollment (October 15-December7) for best value makes one big assumption–that your prescription drug needs in the next year do NOT change. This means that your health does not change for the worse…a tall order especially if you are over the age of 80. For my 80+ year old mom, this assumption went out the window when her health changed a mere weeks after Open Enrollment ended (on December 7, 2017). My mom experienced medical problems that resulted in hospitalization and changes to her prescription drug needs. My mom left the hospital with two new prescriptions (a third high blood pressure drug and a blood thinner). In addition, the dosages for two of her 2017 drugs had been increased. All new prescriptions after my mom’s hospitalization were written by my mom’s family doctor including the heart-related drugs.
New Tasks when Mom’s Prescription Drug Needs Changed
The new Medicare Part D plan tasks I had hoped to complete in the first few weeks in January for my mom hit a snag when her prescription drug needs changed unexpectedly. Once out of hospital, 30 day prescriptions needed to be filled immediately (at a preferred local retail pharmacy). The efficacy and any side effects for these new drugs needed to be assessed for several weeks before more cost-effective 90 day mail order prescriptions could be ordered.
After looking at the 30 day prescription copays for the two new drugs, I discovered two new situations confronting my mom’s pocketbook; namely,
- the new high pressure drug was not on mom’s new Medicare Part D prescription drug plan formulary so the copay was substantially higher than if the doctor (her cardiologist) had chosen one from her plan’s formulary
- the blood thinner was a Tier 3 (preferred brand) drug which also meant a higher copay than she had been paying up until now (all her drugs previously had been Tier 1 and Tier 2 drugs)
I needed to assess these two new situations from both a cost and a risk/benefit analysis standpoint.
Prescription Drug Needs Changed: New High Blood Pressure Drug Not on Formulary
Browsing online, I learned that my mom’s new high blood pressure (hypertension) medication is in a class called Angiostensin II Receptor Blockers (called Angiostensin II Receptor Antagonists in my mom’s Medicare Part D plan’s formulary shown below).
Since my mom’s family doctor was the doctor who had written the new high blood pressure drug, I called her to ask about changing the prescribed drug to one on my mom’s Medicare Part D plan formulary above. The doctor informed me that I would have to call my mom’s cardiologist to make the change because he (and not she) was the one who had ordered the new prescription. Mom’s family doctor also told me that her name was on all the new prescriptions only because the hospital had assigned her with the “medication reconciliation” duty. I found this situation strange and will discuss it further in a later blog post.
I then called the cardiologist’s practice and asked why the new high blood pressure drug was chosen instead of one from my mom’s Medicare Part D plan formulary. I was told that this particular drug was chosen from the hospital’s formulary and the doctors “affiliated” with the hospital are required to use the hospital’s formulary when prescribing. After I voiced my desire to go with an Angiostensin II Receptor Antagonist from my mom’s Medicare Part D plan formulary, I was surprised how easily the nurse practitioner made the change to the Tier 1 drug identified by the arrow above.
The price of the non-formulary drug originally prescribed would have cost my mom much more than the $3 she would have paid for a 30 day supply of the Tier 1 drug shown above. The ease with which the cardiologist’s practice approved the change told me that the two drugs are comparable and interchangeable. A new 90 day prescription for the Tier 1 drug above was electronically sent to the mail order pharmacy before her 30 day non-formulary prescription lapsed. My mom’s copay for this 90 day supply from the mail order pharmacy was $0.
While the hospital’s doctors must know that patients have their own insurance formularies, the minimization of a patient’s out-of-pocket spending is obviously not a priority.
Prescription Drug Needs Changed: New Blood Thinner on a Higher Cost Tier
My mom’s new blood thinner (to guard against stroke) will require greater investigation than allowed by the simple substitution described above. The new prescribed blood thinner (hematologic anticoagulants) is one of the new generation of blood thinners (e.g., Xarelto and Eliquis) which do not have generic equivalents and therefore are very expensive (for example, the retail price for Xarelto is $446 for 30 pills or one month’s supply). As shown in the figure below, my mom has to pay $41 per month for either Xarelto or Eliquis (both Tier 3 drugs in my mom’s new Medicare Part D prescription drug plan.
This one new Tier 3 prescription will increase my mom’s monthly copays for her prescription drugs by more than three times ($20/month versus $61/month). Looking at my mom’s formulary above, choosing one of the generic versions of Coumadin (Tier 1) over the Tier 3 Eliquis or Xarelto would save my mom $456 a year if she purchased it at a preferred retail pharmacy. With an annual income substantially less than the median $23,394 for individuals over the age of 65 (in 2016), a $456 extra expenditure for one drug is a lot of money to my mom.
Even though spending the extra money is a concern for my mom, a risk/benefit analysis needs to be evaluated before making a decision to possibly switch to one of the Tier 1 generic versions of Coumadin. Unlike the new generation of blood thinners, the generic versions of Coumadin require (1) frequent blood testing to identify any dose adjustments needed to maintain effective levels, (2) dietary restrictions (staying away from foods containing high levels of vitamin K) and (3) monitoring certain medication interactions that affect dosage requirements. These dietary restrictions and medication interactions result in drug management headaches not found with either Eliquis or Xarelto. Because my mom has Medicare and a Medigap F policy, the extra blood testing and doctor’s visits associated with the generic versions of Coumadin would not cost my mom any extra out-of-pocket expenditure (but will increase Medicare’s expenditures if she chooses the generic versions of Coumadin). My mom is more concerned about what comes out of her own pocket when evaluating cost considerations.
While a more complete picture of my mom’s health and a risk/benefit analysis between the generic versions of Coumadin and the newer Tier 3 blood thinners should have been discussed with the cardiologist when my mom was in the hospital, this did not occur. The only way this would have happened is if (1) I had been at the hospital when the cardiologist was present (2) I had enough information to ask the right questions, and (3) he was willing and capable of providing the information I needed to advise my mom about her options. For example, I learned that use of these blood thinners can affect kidney (renal) function and some of my mom’s blood tests (which I didn’t have access to until 2 weeks after my mom was discharged from the hospital on her electronic health record) showed some kidney function concerns.
I will delay requesting any change in this new prescription drug need until I can get more information from my mom’s doctors directly. This will require making a trip to where my mom lives (1000 miles away) and going to doctors’ appointments with her.
Other Actions Needed with Cardiologist
Because my mom’s family doctor had her signature (and not the cardiologist’s) on some of my mom’s heart-related prescription drugs after her hospital stay, a discussion with the cardiologist’s practice had to take place. We needed to know if the cardiologist was no longer going to take responsibility for some of my mom’s heart related problems. When confronted with this situation, the cardiologist’s practice agreed that they would take back prescription duties for all of my mom’s heart-related drugs.
What I Learned When My Mom’s Prescription Drug Needs Changed
I have learned three valuable lesions when my mom’s prescription drug needs changed:
- The Medicare Part D prescription drug plan I carefully selected during the Medicare Open Enrollment for my mom may no longer be the best value. Unfortunately mom is stuck with the plan until January 1st rolls around.
- Do not expect the hospital (or your ambulatory care doctors) to know what drugs are on your insurance formularies. Healthcare businesses are not looking out to deliver the most cost-effective medications for you. Keep your plan formulary available for consultation with every hospital and out-patient situation you might encounter. If my mom (or my brother) had had my mom’s new Medicare Part D plan formulary at the hospital, then the non-formulary high blood pressure medication would never have been prescribed. This advice also holds for all healthcare consumers with private health insurance plans with drug coverage.
- Because Medicare is not allowed by law to negotiate with pharmaceutical companies for lower prices, healthcare consumers can expect to be confronted with ever increasing and often unaffordable drug costs. The cost of a single new drug can put healthcare consumers in very difficult financial situations.