Adventures in Medicare Part D.

I was on the phone with CVS specialty pharmacy and the Illinois retired teachers’ Aetna Medicare Advantage people for 90 minutes.

Since April I have been receiving Skyrizi infusions for my Crohn's Disease. The drug required pre-approval (another story for another time) and I was led to believe it was fully covered by my teacher retirement healthcare.

An infusion is done in a medical setting by IV, administered by a medical professional. After three infusions Skyrizi patients are then moved to OBI (on body injections). The drug is delivered by CVS specialty pharmacy to my home. After the first three infusions by a medical professional I inject myself with the same drug once every two months.

For the OBI Aetna charges a $100 co-pay. The main difference between the fully covered, no co-pay, procedure and the ones that come after is the address in which it takes place, who pushes the button, and how insurance codes it.

The first three are a medical procedure and the rest come under Medicare Part D.

This distinction is total bullshit.

Drugs given in a hospital or care facility are covered by Medicare Part A at no cost to the patient. The same drug taken at home comes under Part D and patient payment is required.

It’s a difference without a distinction.

In case you didn’t know, Medicare has been around since Lyndon Johnson in 1965.

It took 40 years for the politicians in Washington thought to include a drug plan for seniors.

Part D was enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006. Under the program, drug benefits are provided by private insurance plans that receive premiums from both enrollees and the government.

It was one more giant gift to the healthcare insurance industry and Big Pharma.

I told the Aetna rep that I would gladly take the Skyrizi over to the infusion center and have a medicare professional press the button on the cartridge to inject me if it would save me the hundred dollar co-pay.

He didn't think that was amusing.

There has been much media coverage of President Biden’s picking just ten drugs that Medicare will be allowed to negotiate the price with the pharmaceutical companies.

The original Medicare Part D law prohibited the government from negotiating drug prices with Big Pharma.

Just ten drugs and not for several years. For those of us in our seventies and older, several years can be a lifetime.

Big Pharma has been crying tears about price negotiations, claiming it will mean they won’t make enough profits to do the research required for drug innovation.

Negotiating prices for 10 heavily used drugs, the government says it will save $160 billion over the next decade.

How this will save Medicare Part D recipients any money is not at all clear.

And Wall Street analysts see only a limited impact on drug company profits anyway.

Government savings are supposed to come out of drug company revenues, but it’s hard to find those revenue cuts in Wall Street’s forecasts.

Drug stocks were generally up on Tuesday, after the administration listed the first 10 products targeted for discounts under the 2022 Inflation Reduction Act.

Barron’s reports that Wall Street analysts believe that the program’s impact on drug sales during its first few years after 2026 will be limited. That’s because most of the 10 listed drugs have been on the market for over a decade and will soon be available as generics.

Another reason for Wall Street’s muted response is that the drug industry is asking courts to block the law’s price negotiations, in half a dozen federal suits. Any preliminary injunction by a court would likely happen before Oct. 1, when the law says the selected drug companies must begin bargaining on the price Medicare will pay in 2026.

Meanwhile I’ve appealed the co-pay charge for my at-home administering of Skyrizi and the representative from Aetna says that it might take several days to get back to me.

At least I don’t have to wait until 2026 for an answer.