Open Enrollment? Part D? Doughnut hole?
Patients come in to the office with pages and pages of printouts asking for advice about their prescription drug plan among other things. Truth is physicians are terrible at this as are many family members of Medicare recipients. Here are some of the basics, broken down Gangnam style.
1. Open enrollment season for Medicare started October 15 and ends December 7. This is the period of time Americans over the age of 65 will need to sort out rules on co-pays and deductibles, formulary coverage (which drugs are covered by which plan), and how the Affordable Care Act (ACA) has changed things for them.
2. Medicare Part A is the part that covers inpatient care in hospitals and skilled nursing facilities.
3. Medicare Part B covers outpatient care. This includes your physician visits and physical therapy. Part B also covers x-rays, vaccinations, chemotherapy, and other outpatient medical treatments administered in a doctor’s office. Examples would be infusions of medications for osteoporosis, rheumatoid arthritis, or cancer given in the doctor’s office.
4. Medicare Part C aka “the Medicare Advantage Program” is a little confusing. Medicare Advantage Plans are offered by private companies approved by Medicare. So a private company contracts with Medicare to provide you with all your Part A and Part B benefits.
Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
5. Medicare Part D. This is an outpatient prescription drug benefit. Unlike Part A and Part B, Part D is not standard. Though the different Part D prescription drug plans are regulated by Medicare, they are private insurance companies who can decide which drugs they cover. Many folks have up to 40 Part D plans to choose from and are left finding the one that best fills their needs.
6. Part D is important because this is how Medicare patients pay for their prescription drugs. You must also learn about the coverage gap, aka the “doughnut hole.” When the amount of money you have paid (as your deductible) together with what Medicare has paid exceeds $2,900 you become responsible for 100% of your medication costs. Wait there’s more: if you reach about $4,700 in out-of-pocket spending Medicare foots most of the bill for the rest of the year.
7. 2012 changes: Some cool changes occurred in 2012 when patients were responsible for only 50% of the cost of branded drugs instead of 100%. The affordable care act (The ACA) anticipates closing the doughnut hole by 2020 at which point Medicare would continue to cover part of the drug costs and you would pay 25% instead of 100%.
On Goodrx you can search for the price of your prescriptions based on which Part D plan you have and in some cases you may find the cash-pay price is cheaper than using your insurance. That part, at least, is easy.
Beware of online pharmacies. Surprisingly, one–fourth of consumers buy prescription drugs online. Fraudulent and illegal online pharmacies offer deeply discounted products so it’s tempting to buy your medications without a prescription and at a cheaper price. But wait until you see the real deal.
The Food and Drug Administration (FDA) took action this week against 4,100 Internet pharmacies selling counterfeit and illegal medicines. Earlier this year, during the week of September 25 – October 2nd, more than 18,000 illegal pharmacy websites were shut down.
What’s the problem?
• Counterfeit drug sales hit $75 billion worldwide in 2010, a 90% increase from the previous year.
• Many of these websites are selling unapproved and potentially dangerous medicines.
• The FDA screened the drugs received through the international mail and found antibiotics, antidepressants, cholesterol, diabetes, and high blood pressure meds headed for American consumers.
• As you all know, many of those drugs could be risky to take without the supervision of a physician.
• Some of the meds being sold had been removed from the U.S. market.
• Other worrisome findings were folks receiving the acne drug isotretinoin (Accutane), which is available in the US only with strict monitoring to avoid pregnancy while on this medication.
• Also sketchy was the antiviral oseltamivir (Tamiflu), which is often sold as a “generic,” though there is no such approved U.S. generic. Tests by the FDA have shown that those generic versions of Tamiflu contain the wrong active ingredient and would not be effective for treating the flu.
What can you do if you want to use an online pharmacy?
• The FDA launched a website called BeSafeRx–Know Your Online Pharmacy. This gives you tips on how to understand who you are buying from and when it’s not a good idea to purchase through a website. You can find a link to BeSafeRx here: http://www.fda.gov/besaferx
• ONLY buy online through pharmacies that require a valid prescription from a doctor; are located in the United States; have a licensed pharmacist available for consultation; and are licensed by your state board of pharmacy.
OR . . . get on Goodrx and find the cheapest legitimate local pharmacy to get the best price for your drugs. Just sayin’
The buzz around Pradaxa has deflated a bit with reports of bleeding risks. Pradaxa (dabigatran) changes the body’s clotting system and thins the blood to prevent clots from forming. Pradaxa is exciting because it is a good alternative to warfarin in patients with atrial fibrillation. Warfarin (Coumadin), unlike Pradaxa, requires serial blood tests to check INR. Pradaxa is much more convenient than warfarin, but is it riskier?
Pradaxa works. In large studies, Pradaxa 150 mg twice daily was more effective for stroke prevention than warfarin in patients with atrial fibrillation. Based on this, in the fall of 2010, the US Food and Drug Administration (FDA) approved the use of dabigatran for patients with atrial fibrillation who are at risk for stroke.
Other than the cost of Pradaxa all news was quite good. That has changed as now there are concerns being raised about Pradaxa. Here are the details: Healthcare professionals and patients were notified of reports of serious bleeding associated with use in patients at a high risk of bleeding, elderly patients, or patients with kidney impairment.
Here are the new recommendations for Pradaxa (dabigatran):
• Due to the risk for bleeding when used in patients with kidney disease, kidney function needs to be assessed before and during Pradaxa treatment.
• If therapy is used in elderly patients (> 75 years of age) or in any patient with kidney impairment, kidney function needs to be checked at a minimum of once per year.
• The FDA is still investigating new reports of serious bleeding associated with dabigatran use.
The FDA will provide updates as they are available. Stay tuned.
Better than Accutane? Yes, a new pill will be hitting the market that works better for acne than Accutane. Absorica (isotretinoin) is a retinoid capsule that dermatologists in the U.S. think will be a game changer in terms of improving acne and preventing relapse.
Why are dermatologists and primary care doctors excited? Absorica is more effective and easier to take than any currently available treatments. It will be available by the end of 2013 for the treatment of severe nodular acne.
How is it different from Accutane? Absorica is more effective because it has better absorption. Absorption is the key difference between how Absorica works and how other isotretinoins, like Accutane, work.
Why is absorption of isotretinoin tablets so poor? Isotretinoin is a highly lipophilic (likes fat) molecule so patients don’t get the maximum benefit of the drug unless they take it with a high-fat meal. This means patients taking Accutane should have been taking it with 50 grams of fat: two fried eggs in butter, two strips of bacon, two slices of toast with butter, 4 ounces of hash brown potatoes, and 8 ounces of whole milk. Ewwww. Then, since Accutane is taken twice daily, patients should also eat another high-fat meal at dinnertime. Since that’s not happening, absorption of Accutane isn’t great.
Better absorption means increased chance for success and lower risk of relapse.
Important note: Like all isotretinoins, Absorica patients and prescribers are obligated to participate in the iPLEDGE risk management program. As you all know, this is the way to prevent pregnancy in our girls taking any of these meds, either Accutane or Absorica.
Absorica was approved by the FDA in May of 2012, and was projected to be available in the fourth quarter of 2012.
Nail fungus is common and there are good treatments out there but you need to be patient. Nail changes are SLOW and improvement will continue after you stop your medication so hang in there. Here are the medications and treatments that do actually work for nail fungus.
The best pill for nail fungus is terbinafine (Lamisil) and evidence suggests it works better than the alternatives with the fewest side effects. Terbinafine results in resolution of nail fungus 76% of the time. It is taken once a day for 6 – 12 weeks. Another good pill for nail fungus is itraconazole (Sporanox) which results in cure 63% of the time. Itraconazole is also taken once a day for 6 – 12 weeks. Remember that improvement will continue AFTER oral therapy is stopped and it may take 9 to 12 months for you to see full results. Though not as effective as terbinafine and itraconazole, oral fluconazole 150 mg – 300 mg taken once a week does result in disappearance of fungus 48% of the time. A new player for nail fungus (a liquid you take by mouth) is Noxafil (posaconazole) which appears to be an effective option though the cost makes it difficult for anyone to afford.
Over the counter fungal creams like clotrimazole and the nail polishes (ciclopirox) are generally ineffective for clearing nail fungus. Ciclopirox (Penlac is the brand name) is a topical nail polish used for the treatment of mild to moderate nail fungus. It just doesn’t work very well resulting in cure only 7% of the time. Medicated chest rub (Vicks VapoRub) has some data looking at its effectiveness. In one study 18 patients applied it twice daily for 48 weeks and 4 patients had resolution. Vicks is a tempting option because it’s so safe and easy to use.
Removal of the nail is only used when only 1 nail is infected, but it does work. Light therapy and lasers are also being studied. A multicenter trial investigating the efficacy of a device, the Pinpointe FootLaser, is currently underway so stay tuned on that.
Last thing . . .
All of the pills for nail fungus can cause liver toxicity so a baseline liver function blood test is required with another one midway in your treatment. Also, your doctor has to look at your medication list to make sure there aren’t any drug interactions. The liver toxicity (which is rare) is reversible after discontinuing the medication.
Treatment failures and recurrences are common so don’t get frustrated, you are not alone.