Getting medications: a tutorial

One of the goals of Prozac in my Corn Flakes is to help others with bipolar disorder.  One of the ways I want to do that is to provide information.  My current career is as a case manager, working with the mentally ill.  My job entails helping to connect my clients with resources so they can live the best quality life they can, and to help them to advocate for themselves and combat stigma.  I’ve been doing this nearly three and a half years, now, and I’m chock full of resources.  Many of them are specific to my area, but I’ve learned a lot in how to search for those resources, which could be applied to anywhere.

Medications, and the cost of medications, is a gigantic barrier here in the states.  The newest medications, which are usually best as far as the smallest side-effect profiles, if not just efficacy, cost hundreds for one month’s supply, and insurance is reluctant to pay for those new medications.  And many people are without insurance at all, because if you are not fortunate enough to have a job with decent benefits, you are often denied based on bipolar disorder being a pre-existing condition.  Those denials will hopefully be ended soon (and hopefully, we’ll all actually get good insurance!) but in the meantime, it’s a big problem.  Additionally, you have the ranks of the underinsured, in which I am one.  I currently have a $5,000 deductible to meet before my insurance will do anything.  My insurance masquerades as helpful by shaving a dollar or two from totals by “negotiating a better price” but then that extra dollar or two doesn’t count towards my deductible, thus keeping me in this ugly cycle longer still.  All I can do is shop around at pharmacies and find the best price, because some pharmacies jack the prices of medications that cost them pennies up to hundreds of dollars simply because they can.

With regards to pharmacies, I’ve had good luck with QOL Meds, who select their prices based on the cost of the medication, plus about ten dollars to actually pay their staff, or based on the lowest retail price offered- they price match all $4 prescriptions, for example, and even if by their calculations they should charge $13, if another pharmacy charges $10, they will match this.  QOL is available in many cities, but unfortunately is not a national chain at this time.  Small family-owned local pharmacies are also great advocates, but often cannot go as low as big-box pharmacies with $4 prescriptions.  However, it is sometimes worth the additional cost to have great, personalized service.  One pharmacy near my office will hand-deliver medications by courier, and will go above and beyond to help negotiate prior authorizations with insurance companies.   I’ve also been fortunate enough to find local pharmacies that have a sliding scale based on income, so they subsidize a percentage if one qualifies.  It’s worth looking into in your area.

Another resource that is something I use constantly as a case manager is patient assistance programs.  Patient assistance programs are programs through the drug company itself where they will provide free medications to those who qualify.  Most programs are based on income guidelines, but writing a long, heartfelt letter explaining the need will sometimes be met with approval, I’ve discovered, for those who make a smidge too much to qualify.  Needy Meds is the best resource that probably exists for locating patient assistance programs available.  You can look up your medication by brand name or chemical name, and download the application.  Most applications want an advocate at your doctor’s office to sign it.  What I did before I had my current job was fill out the application and gather any additional information- usually a W2 or other statement of income- and took it to my doctor’s office.  Doing the legwork yourself will almost always lead to success with your doctor, who will be thrilled that you took the initiative.  Most patient assistance programs will then send several months’ worth of medication to your doctor’s office.  Most programs require a verification after three, six, or twelve months that you are still taking that medication and still have a need, but the verifications are usually easy to complete.  Needy Meds also contains links to other programs, such as drug discount cards, and assistance with locating low-cost clinics and other programs in your area.  It’s an amazing website and probably my favorite tool in my toolkit.

Some people may qualify for state Medicaid programs, but depending on the state, it can be easy or a nightmare to qualify.  Unfortunately, each state gets to set their own rules for Medicaid, so it can be difficult to navigate.  The best way to find out what public assistance resources are available in your area is to call your local United Way. They are invaluable to me when a client is moving and I want to make sure they get connected to the same resources they have here. Additionally, you can start by looking up Medicaid in your state and doing some research on what the rules are to qualify.  You could also try looking up your local Welfare office, which might be called the Department of Job and Family Services, and going there to apply.  In addition to Medicaid, you can apply for food stamps and dozens of other local and state programs that will provide invaluable help to those in need.  There is no shame in receiving public assistance.  It’s there for a reason; to assist the public, and if you qualify, you are entitled to those benefits.  Again, depending on the state and area, there can be an awful lot of hoops, but don’t give up!  The best way to figure out how to navigate the system is to go talk to people there- other consumers- because more often than not, my clients taught me what programs were available and how to use them.  I’m still learning about new programs all the time from clients.

Medicare is run by the federal government, so the rules are actually the same regardless of state. Medicare is for those 65 or older, OR those in the Aged, Blind, and Disabled population. You have to be on disability for a few years (I think it’s two or three) to qualify for Medicare. It is also a bit of a nightmare and headache to navigate. There are different parts to Medicare; Part D is your prescription program. Part D programs vary wildly from area to area based on what companies want to provide it. Each company might have a different deductible and formulary, so they can vary tremendously in overall cost, and might not even offer your medications. Every year, you are allowed to switch plans, as each company can change their formulary or drop out entirely. You’ll receive a letter and probably great big packets of information in November, and you have until January 1st to change plans. Your pharmacist should be able to help you narrow that down, and especially the big-box pharmacies will have a specialist available to counsel you on what plan would be right for you. You’ll want to compare the deductible amount between plans, as well as make sure all of your medications are on the formulary, and compare how much those will cost between plans. You also get to choose a plan when you initially start Medicare and get two months to make a decision. For those who might need extra help paying those deductibles, most areas have a “Extra Help” program offered through their Welfare department. The application usually requires a proof of income, to prove need, and that has to be applied for annually.

Your doctor can be a big help in all of this, and should be your staunchest ally.  If they are not trying to help or support you, it might be time to find a new doctor, if that is a possibility- I understand being trapped by insurance policies, or geographic location.  Doctors can receive samples from the drug companies and might be able to supplement you with those.  Doctors will need to sign off on patient assistance program applications, and doctors can usually help point you in the right direction to get public assistance.  Don’t hesitate to ask your doctor for ideas to help you make your treatment affordable.  Medication is only helpful if you can afford to take it as prescribed, after all.

I am more than happy to help anyone find resources in their area; like I said, I’m extremely good at it.  Just comment and I’ll be happy to help you find whatever you need.  I feel all warm and fuzzy when I’m able to help someone get their needs met. 🙂