Sounds like a dumb question, why would something meant to help people with disability actually CAUSE you to be further disabled? Sad thing is, if you are on SSDI, have Medicare even with an Advantage plan, and your disability causes you to need a biologic medication or other extremely high priced medication, YES it can cause you to become even further disabled.
If like me you are already on Medicare, you are already aware of what Tier 4 drug pricing is. Insurance companies used to use a 3 tier pricing strategy. Tier 1 consisted of low cost drugs and most generics. This is the lowest cost tier. Tier 2 generally consists of name brand drugs that are on the the plans formulary and the co-pays are higher in this tier. Tier three contained drugs that were non-formulary and generally required a prior-authorization. Tier three was the highest co-pay tier. Then in 2009 we were introduced to a new tier. The dreaded Tier four.... This Tier is for newly approved drugs, and a catch all for very expensive drugs, IE: Biologics.
Some states have already banned this form of tier pricing, others are looking into it and there is some movement on it at a Federal level as well. Last September I went to Washington DC with the American College of Rheumatology to advocate. My main topic was this Tier 4 pricing. In my own case, it nearly came to the point of choosing either continuing with my biologic medication (Orencia Infusions) or paying our mortgage. Being I need a place to live and my wife appreciates having a roof over her head, I would have given up the biologic. You may ask about pharmacy companies help programs? If you are on Medicare, you are not eligible for these programs. The Federal Government considers it a kick back, and will not allow this type of help. This is absolutely ridiculous. My speech to our various Reps and Senators was centered on the fact that this could be changed and help thousands and thousands of people while not costing the government a cent. Just repeal the law that denies us the same kind of help anyone on private insurance can easily get. When I was on private insurance and Humira, I paid $5 a month for my biologic. On Medicare with an "Advantage Plan" my co-pay is $490 a month for Orencia!
This of course does not cover just RA, but any illness that requires very expensive medications that the drug companies can lump into Tier four. So, the answer is YES! If you are on disability, it can cause further disability. You hear all the horror stories of people that cannot afford their medications, or only take it sporadically due to the high cost. The sad part is, many of these people are the ones on disability already, many are members of this website. I am passionate about fixing this part of Medicare. IF you can afford your bills, and make enough money to keep your self afloat, that means you cannot qualify for extra help from Medicare........ which pushes you towards poverty.... there is just so much that could be fixed with this system easily, it makes me crazy!
I was fortunate and found a philanthropic group that granted me the copay money I needed to continue my biologic treatment. With out there help I would not be able to keep up with the high cost of all my medications. What will next year bring? No meds? No house? Or a Medicare that makes sense? I am hoping for a revamped Medicare law. I am going back to DC this fall to continue spreading the word. I would ask you if you have any contacts with your states Reps or Senators, please ask them to look into this as well. You can easily find the email addresses for them HERE. If we all speak up, we will be heard!
Published On: June 28, 2012