Wednesday, November 30, 2016

The Doughnut Hole and Other Medical Follies

I got a shock yesterday when I picked up one of my increasing number of prescriptions for what ails me. Hm. One of them had a co-pay of over $80. It had been $10 the month before. The pharmacy was mystified. They said it was an expensive medication, but in the generic form that I received it, even at full price, it shouldn't be that much.

They said I should call my insurance company and see if I can find out what's going on.

So I did, and at first I was told the medication should have a $10 co-pay. When I said it didn't, the person I was talking to looked at my record again and said, "Oh, I see! You're in the Doughnut Hole, and drug coverage is reduced until your out of pocket expenses reach..." whatever it was, I don't remember, many thousands at any rate.

OK. I asked how long this will last, and she was so chipper about it. "Oh, only until Jan 1, sir. Your policy will reset and go back to regular co-pays."

Whew, that's a relief.

My medical expenses have shot up quite a bit since I was diagnosed with rheumatoid arthritis in the spring. I don't see my primary care physician any more since I'm being monitored and treated by a raft of specialists. Each one requires a $50 co-pay each visit. This means at least $150 most months in doctor co-pays. Sometimes more. Then there are the growing number of prescriptions. I fell into the Doughnut Hole because some of these medications cost close to $500 a month at rack rates, and insurance pays the difference between that price and my co-pay. Adds up fast. I knew I was getting close but didn't think I'd actually fall in. Apparently, the newly prescribed drug to control my pulmonary symptoms pushed me over the edge.

Apparently I will now be charged 45% of full price for my medications, but only in December.


My rheumatologist wants me to go to National Jewish Health in Denver for the most advanced treatments for my pulmonary issues.

Well, I have my reasons for being reluctant -- including the length of time it would take to get there, especially in winter -- but I'm game. Seems National Jewish is not. Not that they wouldn't like to see me, just that they can't without specific authorization for out-of-network treatment from my Medicare Advantage insurance company. I have no idea whether that's even possible. The only out-of-network care they pay for is in case of emergencies or need for urgent care when one is traveling outside the coverage area of the company. As long as I'm within the coverage area (most of northern New Mexico) I must use in-network facilities and physicians. There appears to be no exception for referrals by in-network physicians (such as my rheumatologist.)

So. Stalemate on that one.

At least I have oxygen at home and can tank up on it before I go out and about. Eventually, they say they will replace the big tanks with small ones I can carry with me. But for the moment the big tanks and the large concentrator are doing the job.

I'm off to the cardiologist this morning to see if there's any reason for alarm about increasingly frequent chest pains -- because RA can affect all kinds of organs not just joints.

I'm getting a sense of what my sister went through with lupus. I had no idea what that was, and she really never told me what it did her. All I knew was that she was in great pain from time to time, and when she wasn't in pain, she tended to be tired and stiff-jointed. It was often hard for her to get around and do things. But she endured, generally with a smile and laughter. She didn't let it get her down more than a little bit.

I'm not in pain to speak of, so that's good. If it weren't for the medications I'm taking, though, the pain would likely be intolerable. My main problem has been fatigue, but that's partially relieved by the oxygen. The issue that has my doctors worried is the now confirmed pulmonary fibrosis due to RA. It can't be reversed. It's mostly affected my right lung but could spread if not contained/controlled with immunosuppressants -- the corticosteroids and other medications I'm taking. That leaves me open to other risks from infections and pneumonia and such.

So, combined with the inherent nature of medical bureaucracies, I'm just in a whirl, I guess.

And the Ruling Clique is now intent on taking away -- "improving" -- Medicare and Social Security. Throwing more chaos into the lives, old age and deaths of the residents of Dumfukistan. They must really hate us.

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