• harryw410

Medicare Drug Copayments.

July 2, 2022


This is Biktarvy. It is a combination of three AIDS medicines. It is currently helping to keep me alive. Without insurance, the cost for the treatment is about $3,584 a month, for an annual cost of about $43,000. Thank goodness I have insurance.


When I first started taking Biktarvy, I was on insurance from my employer. The monthly copayments were $60. The insurance had a fixed rate for copayments for what they call "specialty drugs." The good news is that the drug manufacturer, Gilead, has a program that covered the copayments. I got $3,584 worth of medication each month at no cost to me.


In 2020, when the COVID pandemic hit, my employer had to cut costs, especially in payroll expenses. They offered me early retirement. I accepted, and went on Social Security and Medicare. My Social Security check is about $2,000 each month after taxes and deductions for my Medicare Advantage plan. I researched many Medicare Advantage plans. The best one I could find for my needs was the AARP United Health Care plan. The drug copayments on this plan, as with every other Medicare Advantage plan I researched, was based on a percentage of the cost of the drug. Remember that $3,584 a month I mentioned above? That's the number they applied the percentage rate to.


For January, my copayment was $1, 264.41. This moved me into a new copayment tier, so the next copayment was "only" $996. Again, I moved to a new copayment tier, so the next 30 day supply was $685.22. That moved me into "catastrophic coverage," so the rest of my copayments for the year would be almost $200 a month. The total copayments for the year were over $4,500. Because the way the drug coverage is written into the Medicare laws, drug companies cannot assist with drug costs the way they do with employer-based insurance. The law was written this way to encourage patients to use less costly generic drugs. But there is no generic for Biktarvy, or other AIDS drugs. The law does not allow exceptions just because there is no generic equivalent. Luckily, I found a charitable foundation to cover the copayment costs.


Recently, I went back to work, and started my employer insurance coverage this week. I'm still on a United Health Care plan, but this one caps copayments at $60 a month for specialty drugs. And Gilead covers that for me. I'm back to no cost to me without having to rely on charity.


I had been blaming the poorly written Medicare drug coverage laws for the high copayments on my United Health Care Medicare Advantage plan. But now I wonder why United Health Care couldn't or wouldn't have the same flat rate copayments for their Medicare Advantage Plans as they do for their employer-based plans.


Certainly the $43,000 annual cost of Biktarvy is outrageous. There are similar outrageous costs for treatments for cancer, diabetes, multiple sclerosis, and many other illnesses. All these patients face the same copayment issues I faced.


I know there is a lot going on with our government right now. Congress is set to vote soon on lowering drug costs for seniors. So far I've heard a lot about reducing the costs of the drugs by the manufacturers.


But lawmakers also need to look at the way the Medicare drug coverage laws are written, and make exception for the drugs that don't have a generic equivalent. Let the drug companies help! They also need to work at the copayment structure of the Medicare Advantage plans. Basing copayments on a percentage of the cost is hitting a vulnerable, fixed income population with an unfair, unreasonable, and impossible burden. Copayment rates for Medicare should be capped the same way they are capped for employer-based insurance.

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