Should old prescriptions be forgot, And never brought to mind? Should old prescriptions be forgot, At formulary time?
Most of you probably know that "formularies" are lists of drugs approved by health insurance companies for partial or full payment "under the terms and conditions of the coverage." Each insurance company has its own formularies, which they change every year on January 1 based as much or more on monetary concerns as on medical ones.
So, now that Medicare Part D Season is coming to an end, it's time to prepare for that overlapping health insurance "holiday" - formulary time! Senior citizens have the privilege of "celebrating" both!
Auld Lang Syne is at least 250 years old, so some of the lyrics do sound a bit "peculiar" to the modern ear. My parody, Formulary Time, follows the same odd patterns and rhymes as its inspiration. After a "cup 'o kindness" or two, it makes nearly as much sense as the original!
Wander with me for a while in auld formulary world to be (hopefully) educated and entertained and to share your formulary stories with everyone.
Although meant for pharmacy students, Making Sense of Medicare Part D - Drug Plan Formularies provides anyone an excellent introduction to the world of the formularies. It explains terms such as tiers, co-payments, prior authorization, step therapy, and quantity limits - all facets of every formulary. Additional key concepts:
One of the most difficult portions of the new Medicare Prescription Drug Plan to navigate is the various drug plans' formularies. Selection of a plan is based on what drugs you are on and which plans provide the best coverage for your selected drugs. In order to select the optimal plan for themselves, it is critical that Medicare-eligible individuals understand how these formularies work. ... However, because of the ability of the insurance providers to negotiate their own "deals" with the drug companies under Medicare Part D, without having to pass the savings on to the consumer, formularies often contain the drugs that these insurance companies are able to negotiate the best pricing on. ... There is one important catch with Medicare Part D that Medicare beneficiaries must be aware of. Once a Medicare Part D beneficiary chooses a plan they are "locked in" to that plan for the year. Now, even though the beneficiary has done all the research to choose the right plan that covers all of their drugs the insurance companies have the ability to switch which drugs are covered under their formulary (with a 60 day warning period).
Yes, and those Medicare Part D beneficiaries better also be aware of what's in this article, reported by the San Francisco branch of the Gray Panthers and numerous other sources:
The number of medications covered under Medicare prescription drug plans offered by the 10 health insurers with the largest enrollment will decrease next year by 26%, according to a recent analysis by Avalere Health, USA Today reports. (See below. According to the analysis, the number of medications covered under Medicare prescription drug plans offered by UnitedHealth and Humana next year will decrease by 30%, from more than 3,750 treatments to more than 2,620, although the plans will continue to have some of the largest formularies available.
There is surprisingly little consumer information available online about formularies. Most of it is links to formularies for specific providers (such as this for one of the Highmark plans), guides for Medicare participants (that typically point to this government site), and fluff from vendors hawking healthcare insurance products.
I don't want to turn this into another piece on Medicare Part D, but Part D and formularies are two sides of the same coin. It's beyond unfortunate that those who are arguably affected by formulary changes the most - senior citizens - turn en masse for guidance from the AARP. Actually, it's more like a crime. AARP only pretends to be a friend of the elderly and any information provided by that organization is suspect at best. AARP not only pushed hard for Medicare Part D, it is profiting from it enormously. I highly recommend the article AARP is drug plan advocate, marketer, originally published by the Philadelphia Inquirer. A few money quotes:
The AARP plans often cost hundreds of dollars more a year than the lowest-priced competitors. ~ That kind of loyalty has pushed the AARP-branded plans to the top of the Medicare heap. ~ The group makes millions from lending its name to Medicare plans. ~ Trust plays a big role in picking a Medicare plan. ~ The array of choices overwhelms even many experts. ~ ...[AARP] has risen to the top because of its reputation as a champion of people age 50 and over. ~ Premiums among the nation's top 10 plans are rising about 21 percent in 2008, and insurers are placing more restrictions on what drugs they will pay for... ~ While its cachet comes from advocacy, AARP is also an entrepreneurial juggernaut that profits from the Medicare drug benefit it helped pass. ~ The Washington-based nonprofit crossed the $1 billion mark in revenue last year. ~ Medicare used to be a quiet market where few needed to advertise. Now it can be an endurance test... ~ Even many advisers say they cannot choose without help. They often work by running a client's drugs through a public program at www. medicare.gov... ~ The federal Web site can be wrong or slow to update... ~ Modeling the needs of a typical patient... ~ The cheapest AARP plan was 33rd... ~ ...the [AARP] cost can be $500 to $700 more a year.
While the pharmaceutical and insurance companies are jumping for joy with record-breaking profits, the rest of us are jumping through hoops. A few personal anecdotes from me illustrate some of the formulary problems. I invite you to share your own formulary stories in the comment section.
My husband was uninsured for seven of the eleven years he battled serious illness. During that time, he was successfully treated with drug A for one of his conditions. He finally got insurance, but with very limited prescription coverage - so limited, in fact, that one refill of one of his medications used up his entire quarter's worth of benefit. Drug A was part of the company's formulary in year one. The second year, it was on the formulary again, but as a "step therapy." The doctor could not even write for Drug A until my husband endured a month of Drug B and the doctor wrote a letter stating why he indeed needed Drug A. This was EVEN THOUGH THE INSURANCE COMPANY WOULD NOT BE PAYING FOR IT! Year three, Drug A was inexplicably on the formulary again with no restrictions and Drug B remained. Year four, Drug A was not on the formulary at all. Drug B was also gone. Thankfully, a new Drug C was on the formulary that did help as much as Drug A had.
Multiple this chaos times the nine drugs my husband took regularly.
A few months ago, I finally got health insurance for the first time in seventeen years. I am grateful to have it, especially because drug coverage is included, since I take four expensive life-saving medications. However, right off the bat, two of them had to be changed because they were not on the formulary and a third required letters and phone calls from my doctor before she could prescribe it. I am not authorized to have the blood work yet which will reveal whether the two switched drugs are working. No matter. I received a copy of the 2008 formulary in November. Two of the four drugs I am on now are no longer on the formulary!
Multiply this lunacy times millions of patients taking thousands of drugs.
In November, the local mom and pop pharmacy demonstrated common courtesy and good business sense by calling every single regular customer, including me, to warn them that there would be major formulary changes and reductions on January 1. They sought permission to fill every prescription they could before the new formulary takes effect. This was extremely helpful to me and not only did the drug store ring up as many sales as possible, they avoided at least some of the problems they will surely encounter starting January 2. My doctor's office also called me last week to change one of my scheduled appointments in January. Instead of seeing patients that day, she will be attending an out-of-town educational seminar on the new formularies. When she returns, she will then have to train the other doctors in the practice and her staff.
Multiply this insanity by thousands of pharmacies, hospitals, and doctors.
Human lives and billions of dollars are at stake. The time and money spent attending to formulary issues is wasted instead of being used for actual patient care. The stress to patients, their families, and their healthcare providers is incredible - and unnecessary. It's not a game, except to the profiteers. The rest of us are being manipulated by this formulary madness.
Well, I don't know about you, but I'm certainly ready for a song!
I was amazed to find that Auld Lang Syne has a rich history as much more than just a song for New Year's Eve. In different parts of the world, it is played and sung at weddings, graduations, and funerals, and it has even been used as a national anthem. There are many variations on the lyrics. Try this particularly fun set at your next New Year's Eve party:
Should auld acquaintance be forgot, And never brought to mind? Should auld acquaintance be forgot, And days of auld lang syne?
Jan Anderson is "finding herself" at 50. Jan was a bra burning, picket sign carrying, hippie flower child when she was young. She organized her first protest in the 4th grade - against the rule that girls weren't allowed to wear pants to school. When she was 16 or so, she marched in favor of 18-yr-olds voting. About the same time, she was campaigning for McGovern and against the Vietnam War. Although Jan never lost her ideals, she was not politically active during the years she and her husband worked while raising two fine, free-thinking sons. Well, she's back. Now widowed and disabled, her pen and her wit have become her weapons of protest. Jan writes often, mostly about political issues, but sometimes about illness, grief, family, or pets. Most of her work is intended to be funny as well as serious and includes large doses of sarcasm, satire, and, especially, musical parody. She calls her songs "Parodies for Progressives." Jan posts at three other sites under the name nightowl724: Daily Kos, The Smirking Chimp, and Cure This. She also occasionally writes book reviews at Amazon.
The pharmacy system in the US is designed to benefit profits not patients. Perhaps there a slogan in there somewhere. I don't believe that the US system is a problem it is an obscenity. A country that is so rich and yet so heartless to it own most vulnerable. The people (The Congress and next administration) should tell drug companies enough is enough.
The Capitalism of the founding fathers was that of Idealistic or overly naïve of Adam Smith. His view of capitalism was that at worst it was benign and at best supportive of the population. We all know that capitalism as he perceived it was still born.Concepts like the ability to negotiate in good faith and fairness have been subsumed with greed and indifference to the suffering of others. (major corporations in this case Drug Corps.)
Capital has successfully imbued the public with a paranoid terror of Communism (another concept that was still born. USSR was nothing like Marx’s Communism in ‘Das Capital’). The average American can’t see the difference between Communism and Socialism and as a consequence Socialized anything is an anathema. In other countries the ‘purchasing power of the governments ‘have reduced the costs with patient subsidies to a point that all those who need drugs can get them.
The Drug corps have divided and conquered by negotiating with smaller (less bargaining power) organizations this sleight of hand and orchestrated spin and misinformation campaign maintains obscene profits.
The furphy is often stated that Americans are subsidizing the rest of the world because of the high cost of development this is blatant rubbish. Sure the costs are high but the profits are stratospheric.
Then there’s the dodges the phony way they increase the life of patents by adding an extra component and calling it a new product.
Or raiding third world indigenous botanics for therapeutic compounds and when they are found buy the rights of the plant from a botanical garden in a first world country for a pittance of royalties they might have to pay the country of origin, not that a few $million is much when compared to the tens of Billions reaped from sales. By the way this raiding native medicines also saves on costs.
A particularly callous example is that of the appetite suppressant that is derived from a Kalahari cactus (part of the native medicine of the San [the genetically oldest race on earth] who are endangered due to diamonds and exploitation). The drug company agreed to pay $5 million for the rights for a compound they believe is worth $15 Billion…..5 years later the San have received nothing but the drug company is actively marketing the product. The company said in a statement that the San have the right to go to court if they’re not happy. The San believe that $5 million is enough to get them a better existence and saw no point in asking for more. Pity the Drug Corp didn’t have the same sense of enough is as good as a feast.
Yet America languishes near the bottom of W.H.O. listing of health systems in developed countries. The fact that Americans aren’t enraged especially given that it directly affects them all stuns me. One wonders what it will take for the people to assert their control over a hijacked system.
While an activist also 16/17 for the right to vote for the indigenous people and against the Vietnam war my interest in dispensing with bras was ashamedly some what more carnal in intent.....well you can't have everything. Some say I have suffered in life because I never lost my overactive Humanist streak but I guess that's a matter of perception..... anyway welcome back and keep up the good work......P&L
by
Andris (4 articles, 0 quicklinks, 0 diaries, 531 comments)
on Monday, December 31, 2007 at 7:30:53 PM
I checked out your articles and several of your comments. I especially liked the article on Egypt and I learned a lot from it. Your comment on the effect of all "reporters" becoming "journalists" was so true...
The ENTIRE healthcare system in the US is about "profit, not patients!" And, obscene is definitely the right word, Andris. Big Pharma and Big Insurance in particular seem to have endless tricks up their sleeves, such as those you listed about re-gifted patents and robbing the San. In the US, we defend our right to spend the most on healthcare and still rank low among other industrialized nations as far as quality and availability!
Americans aren't enraged because Americans aren't engaged. Sometimes I think this is because Americans are "too busy" watching the "Survivor Island Celebrity Idol Shopping Channel" to THINK. But more often, I believe we are suffering from collective depression/Post Traumatic Stress Disorder or that we are overwhelmed merely trying to survive. Hungry people are easily controlled.
Your statement that your support of bra-burning was "more carnal in intent" made me laugh! Hmmm... Thinking, caring, hoping, and acting DOES hurt at times. It would be so much easier just not to give a damn! However, that's not who we are. I cling to the thought that, together with the voices and actions of others like me, we can indeed make the world at least a little better...
I have posted many political diaries and parodies at Daily Kos. Since you liked this one, I thought you might also like these healthcare-related pieces of mine:
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