6 June 2022
On Friday, I called Cat the Physician's Assistant to find out what was going on. She said she'd call the pharmacy and get back to me. And she did within the hour.
The pharmacy told her Joyce was in the donut hole of Medicare Part D prescription drug coverage. So Joyce has to pay full price until her total for the year reaches $7,000, about $3,000 more.
There are some workarounds, Cat said, that we can pursue with Kaiser Member Services. The pharmacy will call, she added, to explain.
They never called.
Meanwhile, we did a little research. Joyce's first quarter Part D statement showed she had paid just a few pennies over $1,026 so far, well below the $4,430 threshold for the donut hole in coverage.
The problem, according to the pharmacy, is that the prescription quantity is assumed to be for 45 days.
So today we called Member Services to confirm there had been no mysterious May addition. No, we were still well short. Nothing added in May.
Member Services recommended we call the pharmacy, which had a 45-minute estimated callback time. In fact, they put us in the queue.
When they called back, the pharmacy this time confirmed Joyce was well short of the donut hole. But her insurance coverage restricted her from re-ordering Santyl until June 22. So she was being billed full price.
The problem, according to the pharmacy, is that the prescription quantity is assumed to be for 45 days. So we can only refill an order, for any quantity, once a month. And the reason Joyce was quoted $3,000 for the large Santyl order was because we were ordering before June 22 (which is true even for the new 90g order Cat had just placed, which would cost $900 if we got it before June 22).
I explained that we are on the last tube of the May 22 order and won't make it to June 22. We (quite conservatively) use just 30g a week. How we could secure 120g for a month instead of just 90g for three weeks?
The pharmacy said to tell your doctor to order the quantity you need for a 45-day period.
So that would be six weeks or six tubes or 180g for about $180, which is feasible. And not the $1,800 full price.
I sent Cat an email asking her to order 180g of Santyl. That should cost Joyce $180 on her Medicare Part D plan. And not the $1,800 full price.*
Joyce finds the whole think bewildering. It's clear the pharmacy has made up a few answers along the way. And, as Cat said on our phone call, doctors unfortunately don't know the rules of the prescription game.
I've known since tracking my father's misfortunes nearly 20 years ago that every patient needs an advocate. But even a well-meaning advocate is at a disadvantage, learning only crisis by crisis.
Some system.