Local pharmacies power through Medicare issues

By Tony Waggoner, Staff Writer
Published: February 29, 2008 06:19 pm
http://www.enidnews.com/progress2008...060181948.html

Certainly, one of the biggest political topics of the last few years and probably the next several years to come has been Medicare. In the last two years, the topic of Medicare has turned toward prescription drug plans covered by the program.

Medicare is a social insurance program administered by the United States government for people 65 and older, or for people who meet special criteria needs. The health insurance program went into effect July 30, 1965, as an amendment to Social Security legislation.

January 1, 2006, Medicare Part D went into effect, providing prescription drug coverage for Americans on Medicare. Part D coverage is set by private insurance companies and not standardized. Plans only cover certain medications or classes of medications and allow the insurance companies to determine the monetary percentage they will cover. Steve Pryor, of Scheffe’s Pharmacy in downtown Enid, said he believes there are currently 40 to 50 different plans for Medicare Plan D.

“Co-pay is set by the insurance company,” said Greg Diel, of Family Pharmacy in Enid. “They will rise or change yearly, which is a little more confusing for the elderly.”

The plans change Jan. 1 every year, Diel said. He said this creates some confusion for several of his older customers because they will come in anticipating paying the same fee they have before and have to pay more.

Pryor said a major issue is with the insurance companies list of preferred drugs. A doctor might prescribe medication that is not covered under a patient’s plan. Generic medications are often the solution, but some drugs don’t have generic versions.

Certain drugs, like benzodiazepines, cough suppressants and barbiturates, are excluded completely from the plans. Plans that cover these drugs cannot pass the costs on to Medicare. If Medicare is billed, plans are required to repay the Centers for Medicare and Medicaid Services. Patients receiving Medicaid are eligible to receive coverage on some controlled substances. Some beneficiaries are dual-eligible for both.

“One of the other things I’m seeing is some plans are strongly encouraging mail order,” Diel said.

He said many customers have chosen to go online to purchase their medications, only to find out they have to wait to receive, often leaving them without their medications. In these cases customers have come into the pharmacy and requested refills, and Medicare will not pay for it, since the customer’s purchase online for that fill has already been registered. This forces customers to pay out-of-pocket, which can be very expensive.

Other Medicare plans offer a type of supplemental coverage, called Medigap, to help reimburse payments made out-of-pocket. This currently only pertains to Medicare Plan A and Plan B, which deal with hospital and medical costs. Plan D currently does not have a payment plan to help fill “donut holes” for out-of-pocket payments.

Both Pryor and Diel said the plans have created a lot more paperwork for their pharmacies and rebates from the insurance companies can often take an extended period of time. Diel said it involves the amount of money he is spending to bring in medication versus the amount and time it takes to be reimbursed by the insurance companies for Medicare patients.

“The issue we run into is a cash flow problem,” Diel said.

The pharmacists both agree, though, that Medicare is helping patients. Pharmacies are able to keep patients Medicare information on file.

“I think it is a good thing for consumers, especially the low-income subsidiary, Pryor said. “They don’t have a gap. They have a flat co-pay all year long.”