Obamacare: plan cost tripled, how to maximize Medicare benefit

I have scleroderma. I’ve been on Medicare about six years now, and also have another health plan.   I kept the other health plan because Medicare would not pay for the drug I need for my scleroderma.  I take Viagra which keeps blood flowing to my extremities do I don’t lose them!

My health plan was $175 per month, but went up to $670 per month.  I am on a limited income. I cannot work. I cannot afford a $500 increase in insurance per month.  My income is $30,000 a year.

My Viagra alone costs almost $40,000 per year. (One of 8 drugs I take). What am I to do? Even if I get on a Medicare advantage plan and got a medical waiver for Viagra, I would have to pay $5000 out of pocket before I reach the donut hole. Do I buy prescription drugs from India now????  Viagra is 50 cents a pill compared to the $25 price tag here in The US. Please help.

Spry in Florida

 Dear Spry in Florida,

If I understand correctly, your “other” health plan duplicated your Medicare coverage, except for the drugs.  And as you now know, a full, health-reform compliant plan is quite expensive.  Fortunately, you do not need such a plan: you have Medicare.  You will want to get Part D drug coverage, which will cost you a great deal less than your old health plan did.  The average Part D plan monthly premium is around $40.  Sorry to say, your income is too high to get Florida’s “Medicare Savings Program” which would help you pay your Medicare premiums, co-pays, and deductibles, unless you have a spouse that you didn’t mention.

You mention getting onto a Medicare Advantage plan and being caught by the doughnut hole.  The ACA has shrunk the doughnut hole, but when all is said and done, your maximum out of pocket is still $4,550.  Once you had spent that much out of your own pocket, you would pay only five percent of your drug costs; this phase is sometimes referred to as “catastrophic” coverage.  (For those new to the doughnut hole, here is how it works: in 2014, once you and your plan have spent $2,850 on covered drugs, you’re in the coverage gap.  That is not $2,850 out of your own pocket; it includes the amount that the plan paid on your behalf.  Once you reach the coverage gap in 2014, you’ll pay 47.5% of the plan’s cost for covered brand-name prescription drugs and 28% of the price for generic drugs.) 

Viagra is available as a generic drug in Europe and Canada, but is protected until 2020 from generics in the U.S.  It is technically illegal for people in the U.S. to buy drugs from online Canadian pharmacies.  However, apparently, federal officials are choosing not to enforce this law for drugs that are non-narcotics or non-controlled substances.   You may want to read the FDA’s Consumer Guide to Online Prescription Drug Buying.

I’m not sure whether your expenses for online pharmacies will count toward your Part D deductible or maximum out of pocket.  If so, you could have the best of both worlds – cheaper drugs and benefit coverage.

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Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.