Donut Hole

[i61164]

---

Members do not see this ad.

My grandmother's sister has paranoid schizophrenia and she takes several medications which cost about $700 per month. Before medicare part D, she received the meds free from the pharm companies because she has a very low social security income. Now that she has medicare's awesome new prescription coverage, she can't qualify for the free medicine from the drug companies. So for the first 6 months of the year, Medicare buys her medicine and she just pays a copay. Then, she hits the "donut hole" and she had to pay 100% out of pocket. Obviously, due to her condition she cannot work to earn enough to pay for these drug. My poor 70 year old grandmother has been working to support her sister. She was working in a grocery store bakery for the last few years but was laid off recently because she is no longer strong enough to lift the huge bags of flour. Now she is working at Panera, but she took a substantial pay cut.

When I get my M.D. in 2.5 years, I am thinking I can get free drug samples to send to my grandmother, but I wish I could do something now. My aunt is taking Seroquel, Paxil, and Lipitor (my grandmother is going to e-mail me complete list of meds with doses soon). Is it possible to get free sample of these? She has been on the Seroquel for over 5 years and hasn't had a single hallucination since being on it. Do you think I could ask a psych resident that I know to try to get me the samples? Would it be inappropriate?

 

[sdn1977]

My grandmother's sister has paranoid schizophrenia and she takes several medications which cost about $700 per month. Before medicare part D, she received the meds free from the pharm companies because she has a very low social security income. Now that she has medicare's awesome new prescription coverage, she can't qualify for the free medicine from the drug companies. So for the first 6 months of the year, Medicare buys her medicine and she just pays a copay. Then, she hits the "donut hole" and she had to pay 100% out of pocket. Obviously, due to her condition she cannot work to earn enough to pay for these drug. My poor 70 year old grandmother has been working to support her sister. She was working in a grocery store bakery for the last few years but was laid off recently because she is no longer strong enough to lift the huge bags of flour. Now she is working at Panera, but she took a substantial pay cut.

When I get my M.D. in 2.5 years, I am thinking I can get free drug samples to send to my grandmother, but I wish I could do something now. My aunt is taking Seroquel, Paxil, and Lipitor (my grandmother is going to e-mail me complete list of meds with doses soon). Is it possible to get free sample of these? She has been on the Seroquel for over 5 years and hasn't had a single hallucination since being on it. Do you think I could ask a psych resident that I know to try to get me the samples? Would it be inappropriate?

Every state has differing rules on how samples are handled. You'll get differing opinions from the physicians here, but coming from a pharmacist's perspective....I think you'll be putting your resident friend in an awkward position of providing medication (which, depending on the state rules of how samples are handled) should be provided in the course of providing medical treatment. When that physician is not actually treating the patient, then they walk a fine line of "peddling" or "supplying" medication without a good faith examination - which is what gets internet physicians & pharmacists into trouble.

I think they'd tell you no because the risk to their future licensing is not worth it.

Now....to give you some positive resources to actually help your great-aunt: What state do they live in? If her income is so low that she previously qualified for pharmaceutical assistance programs, she will probably qualify for Medicaid. By becoming Medicaid qualified - she then becomes what we call a "dual eligible" Medicaid/Medicare patient & these patients never fall into the Medicare donut hole.

The place to begin is to start with social services within her state. They will evaluate her income & her expenses. They will then send letters to all the medical providers (physicians, pharmacists, etc..) & we will document what the last year's expenses have been & what we estimate the current year's expenses to be.

Additionally, pharmaceutical assistance programs do also provide assistance when pts fall into the donut hole even though they don't require it all year long. Since the new Medicare year has begun, they have time to work on the documentation they'll need.

Good luck!

 

[i61164]

Thanks for responding. They live in Oregon. I actually got the idea of free samples because one of the doctors that I shadowed (here in NC) gets free samples from drug reps for his family. My great aunt has a social security income of $350 per month but she only gets about $50 per month after all the insurance premiums are taken out (so I'm told). She also receives alimony of $1000 per month. I am not sure if she qualifies for Medicaid, but I guess that's worth a shot. According to my grandmother, she reapplied for the pharmaceutical assistance programs in 2006. She says that she had to fill out five different applications (providing proof of income and bills) and that all were denied for the reason that "she has pharmaceutical insurance."

 

[ntubebate]

Hon,
Lets work with what we got here. If you could get my a complete list of her mediciations and even PM it to me, I can usually come up with some generics that will save big money. I have tons of patients who are un-insured.

For instance, you note she is on Paxil. Paxil is now availble as a generic and if you go to Wal-Mart you can get a month's supply for a whopping $4. Yes, $4.

Also, you note she is in Lipitor. If her lipids are really bad, lets move her to Zocor, who's generic simvastatin is about 1/6th the cost of her Lipitor. If her lipids aren't too bad then lets move her to Pravachol which again, is availble in generic form from Wal-Mart pharmacy for $4.

I don't work in any way for Wal-Mart but lets face it, their new $4 Generic Drug program may save a crap load of lives. People who couldn't afford their ACE or Statin now can get quality medicines for $4 each for a month supply.

Again, if it helps, PM me. I'll do what I can.

ntubebate

 

[i61164]

I like this idea. I am going to work on getting that list to see what we can do.

Thanks.

 

[whopper]

ntubebate has given some great data.

However let me give some points.

If she has hyperlipidemia, paxil & seroquel are not exactly the best meds. Metabolic syndrome has been highly tied to both these meds.

Out of all the SSRIs, paxil is perhaps the worst. It causes the most amount of weight gain. Seroquel, while not being the worst atypical antipsychotic for metabolic syndrome isn't the best, in fact far from it. Its close to the worst, though not the worst.

As ntubebate stated, there is generic paxil available. There is also available generic welbutrin (buproprion) which actually causes weight loss in studies. Prozac (fluoxetine) is available as a generic, is much cheaper than paxil and causes less weight gain.

As for Seroquel, if you want an atypical that has a better metabolic side effect profile, risperdal, geodon & abilify are all available and in fact are actually cheaper than Seroquel which is one of the more expensive atypicals.

And to add to my criticism of Seroquel, on the CATIE trial, it had some of the worst ratings of all the atypical antipsychotics in terms of long term compliance. Based on the results of the CATIE, my preference for giving that med has gone from neutral to low.

I do though need to state that I'm just giving points of information to consider for your grandmother to discuss with her doctor. No doctor should practice over the internet by text.

 

[ntubebate]

Yes, it goes w/o saying that anything I suggest should only be acted up by speaking with your grandmothers physician and done under his direct and prudent supervision. I flatter myself as being a good physician but I'm not good enough to treat people over the internet... not yet atleast 😉

One thing I want to elaborate on from the previous post and perhaps pose for question is, what about a TRUE typical antipsychotic? Seroquel and Paxil are w/o a doubt contributing to her unfavorable lipid profile and she has probably packed on some pounds from it. I'd be more comfortable with a Celexa (generic citalopram/availble on the $4 drug plan) and Wellbutrin SR (generic also availble) to see if she could drop some weight. If she happens to be a smoker or have a chronic pain syndrome or low energy (who doesn't at her age) then Wellbutrin (my new favorite drug-Wellbutrin XL) may have benefits above and beyond.

Finally, I read the CATIE study in the middle of the night (I think) and am a little sketchy (need to reread when more coherent) but didn't it favor the usage of more typical antipsychotic drugs? Perhaps Mellaril, Prolixin or *gasp* Haldol?

Hope this helps,
ntubebate

 

[whopper]

CATIE I in a nutshell showed that atypicals are not the superior power houses they were thought to be vs the typicals.

While many people eventually do become noncompliant on typicals, a similar amount become noncompliant on atypicals, but for usually different reasons. Typicals-had the expected EPS problems, but atypicals often had metabolic or nonefficacy problems.

CATIE I & II showed Seroquel having the least (or was it 2nd least--I haven't read the article for a few weeks and I'm not at my home tonight) amount of compliance and the worse levels of efficacy among all the atypicals.

This, added to the problems that it is not favorable for metabolic effects, and that it was not superior in preventing EPS sx vs other atypicals, and that it has strong abuse potential with a high street value doesn't have me liking this med. I used to think Seroquel may have superior effects on negative sx or reduced rates of EPS but CATIE I & II showed all atypicals to be similarly effective in negative sx and all yielded similar EPS rates.

When it came down to it, the only real differences between the atypicals were efficacy (Clozaril came out on top, followed by Zyprexa, then Risperdal, then Geodon, then Seroquel).
Long term compliance-Clozaril I believe still came out on top (but again I have to rereview this), next were Zyprexa & Risperdal (Zyprexa was superior to Risperdal but not significantly so). Then Geodon and Seroquel. Seroquel was on a significantly lower level than the others.
Price: Zyprexa and Seroquel are very high up in price compared to the other atypicals
Prolactin: Risperdal caused the most amount of prolactin related side effects.
Metabolic profile: Clozaril & Zyprexa were strong harbingers of weight gain & hyperlipidemia. Seroquel was then the next worse. Risperdal had some surprisingly mixed results on hyperlipidema (again need to double check this). Geodon was able to hold up to its claims on being the most weight neutral.

Abilify as most people know was not included in the study.

Pfizer/Geodon since the CATIE has now suggested to docs to increase the dose to maximum. Geodon was on the tail bottom for efficacy in the CATIE (again I believe Seroquel was the worst), but the dosages in the study varied. Pfizer reps (at least the ones in my area) now suggest that increasing to the maximum dose may yield increased efficacy.

Again, while I have read CATIE I & II several times (and I suggest all of you do if you haven't, its the new standard) I didn't write this post with either study in front of me. If anyone notices any errors in my post please reply with corrections.

 

[i61164]

My aunt has gained a lot of weight and she does not exercise. In fact, she has trouble getting around becuase of muscle atrophy. I will advise my grandmother to talk to her doctor about alternatives to Paxil. The Seroquel, from what she told me, is not likely to be changed because because it is working and she tolerates it (they have tried many drugs over the years). In fact my grandmother attributes the weight gain to Seroquel (right or wrong) and says that it is still worth it. I suspect that a big part of the weight issue is diet/exercise and that is unlikely to get better. Maybe switching to another antidepressant will help.

 

[whopper]

Wellbutrin & Prozac have a little effect where patients get some added "zing" because both are stimulatory.

Seroquel & Paxil also causes some strong sedation which may contribute her not moving around.

I hate saying it, but again, Paxil & Seroquel are perhaps in the worst in their classes for not only metabolic syndrome but also sedation.

I don't know what has and has not been tried but the following are the atypical antipsychotic meds in order, best to worst in terms of preventing weight gain & hyperlipidemia.

Geodon & Abilify (studies show both are weight neutral, but Geodon has more data backing it up on that).
Risperdal (several studies some variable results, but CATIE showed Risperdal to definitely be far better than the following meds.)
Seroquel: significant weight gain and sedation
Zyprexa:significant weight gain, hyperlipidemia and sedation but more so than Seroquel
Clozaril significant weight gain, hyperlipidemia and sedation but more so than Seroquel

I'm not sure if her doc is considering her metabolic profile or not. Perhaps he/she is, perhaps not.

The bottom line: a doctor should to everything to help a patient achieve both good metabolic control and control of psychotic sx, but if one has to chosen over the other, its almost always control of psychosis over metabolism.

So the doc either has tried to control the metabolism with the other drugs and they didn't work, didn't give them enough of a try or just didn't consider metabolism.

Another thing to consider is several atypicals do not reach full benefit for several weeks. In some cases, a patient may switch to another atypical believing that the 1st did not work, when in fact it would've worked if just given another week or 2. I would only try to stop an antipsychotic if a patient has been on it after the maximum dose has been achieved and its been 6-8 weeks with no benefit whatsoever, and I strongly believe the pt has been compliant.

 

[sdn1977]

Polar Bear - I'm not a psychiatrist so I'll give you no advice concerning her medications & what's appropriate medically or not. However, you did state your great aunt is stable & has been for some time. That right there says a lot.

Now....I will say I can speak with significant authority with regard to Plan D since I deal with it daily (oh - about 50-60 times per day!). It is a NIGHTMARE to put it mildly & your great aunt is just one, albeit a significant one, of many, many folks who are suffering for it. Drug changes require office visits & lab work....some follow thru & some don't. Part D holds all the cards - there is no requirement the formularies stay the same throughout the year & most physicians I work with want to see the pt after changing the drug - another copay.

Now...I'm going to give you some practical alternatives to offer - which in no way discounts what whopper & ntubabe have put forth which gave you profound medical drug information. However, I can imagine how difficult it is for you to translate this information from where you are in NC to your grandmother, who is not your great aunt's caregiver, in Oregon.

So....you could perhaps intervene & offer the medical suggestions which have been put forth here - which are probably the best medically. However, practically speaking...you are looking at taking Step 1 in 3 months - so I'm thinking you're not going to be able to spend too much time in Oregon with your grandma & great aunt and they or may not be able to understand & give that information to her physicians (since there are probably more than one - a psychiatrist & someone prescribing the statin).

Unfortunately, your great aunt has made her choice for 2007 Medicare - the enrollment period was Nov. She cannot change it now. But...I would STRONGLY encourage your grandma to help her sister with pursuing the social work side of Oregon's Medicaid. I looked on the website...which you, yourself can access - oregondhs.gov to find the eligibility rules. For the medically needy, the resource limits are $2000 for one person (this excludes a home and one car). However, she may or may not be medically needy & if she is, if she qualifies, she would have to seek her mental health services from community mental health programs - something she may not want to do.

Likewise, there is an elderly/disabled Oregon Supplemental Income Prgram Medicaid (OSIPM) which she may qualify for. It is too difficult to estimate what she might be eligible for since none of us are from Oregon & don't know their rules.

Now...none of this will work for 2007, since her participation in Part D will exclude her from participating in Medicaid alone - unless she qualifies as a dual eligible patient, which CA eligible Medicaid pts can be. So...it pays to have her start the process now rather than later. She also needs to seriously consider if she wants to stay with Plan D for 2008, especially if she qualifies during 2007 for Medicaid.

As for the Part D plan - it is only going to become worse! From a medical perspective, the donut hole provision penalizes the sicker patients with substantial drug needs. Of the top 25 drugs most commonly prescribed for seniors, 18 are not available in generic form....therefore, whatever possible donut hole coverage which might be available is meaningless. So caution her to not randomly sign up for donut hole coverage! In addition, the size of the donut hole is not fixed - it is tied to the cost of the drugs. In 2006, the donut hole began when the drug expenses reached $2250 & ended (catastrophic threshold) was $5100. In 2007, it begins at $2400 & ends at $5451 - the size of the donut hole increases by $250.

Now....what are her choices given she does not want to change drugs - which require more doctor visits & possible labwork? As ntubae suggested...if she has drugs which fit in the $4 Walmart or Target drug plan....that is possible. However....I would encourage her to utilize her 90 day provision for Part D coverage first. She can get 90 days for the same copay as 30 days, if her plan & her physician allows....Depending on which Plan D she signed up for, her copay for 90 day supply may be less than $12 - seems a small amount to us, but it adds up for them.

For the brand name drugs which become expensive once she enters the donut hole - Lipitor & Seroquel....I'd recommend what I've done in the past for actual patients of mine who have lost their coverage for a number of reasons.....you can go to a US approved online pharmacy (pm me if you want to know which ones are licensed & recognized as reputable by the National Association of Boards of Pharmacy) or you can use a Canadian pharmacy - a brick & mortar pharmacy ONLY. You absolutely DO NOT WANT to utilize JUST ANY online pharmacy since drugs coming thru South America & Asia are notoriously well known for being adulterated. Personally, I would use a US online pharmacy since they are about $10 cheaper ($43.90 for 30 day supply of Lipitor 10mg vs $55.80 for Canadian - in US dollars).

She is in a difficult position & most seniors don't know what their alternatives are & actually have a hard time navigating the online information. Pharmacists are in a tough spot - we don't want to lose our patients - since we feel we help them stay compliant. Howeve, we do know the realities of cost.....so your family needs to weigh all the costs - drug as well as physician visits & labwork which might be required if she changes medications.

Good luck - its admirable you care so much to find solutions. And....best of luck on Step 1!!!!!

 

[sdn1977]

Polar Bear - one more update!

Oregon passed Measure 44 last Nov. This expanded Oregon's Prescription Drug program. The newly eligible people covered are those whose health insurance plans do not cover prescription drugs AND Medicare Part D beneficiaries who have reached the donut hole & before catastrophic coverage begins.

For details, visit www.aarp.org/ or to sign up for benefits go to www.opdp.org or call 1-888-411-6737. I hope your grandma can help get her sister the coverage she needs to maintain her current stable situation.

Best of luck again!

 

[i61164]

Thanks for all the replies. You are right that I don't have lots of time to work on this but I am trying to give my grandma advice over e-mail. She is only now learning how to use e-mail and I have yet to hear back from her. I am going to have my sister (who lives in OR) help her get into her e-mail account so she will write back to me. I'll let you guys know how it goes. I appreciate all the help.

 

[i61164]

Grandma finally wrote back and here is the complete list:

Hydroxyzine HCL 50 MG
Lipitor 20 MG
Paroxetine (Paxil) 20 MG
Ranitidine 150 MG
Zyrtec 10 MG
Seroquil 200 MG
Premarin 0.625 MG

So it looks like she is already on the generic Paxil. In terms of just saving money (without trying to switch anything around because of metabolic syndrome - I'll let her doctor handle that) is switching the Lipitor to the generic Zocor the only thing we can do? I'm also going to see if they can do the 90 day mail order thing because that should be cheaper as well.

According to my grandmother, since it is now January she will have to pay the annual deductible of $250 and then insurance will cover 80% up to $3,000. She says last year they hit the donut hole in August.

 

[sdn1977]

Grandma finally wrote back and here is the complete list:

Hydroxyzine HCL 50 MG
Lipitor 20 MG
Paroxetine (Paxil) 20 MG
Ranitidine 150 MG
Zyrtec 10 MG
Seroquil 200 MG
Premarin 0.625 MG

So it looks like she is already on the generic Paxil. In terms of just saving money (without trying to switch anything around because of metabolic syndrome - I'll let her doctor handle that) is switching the Lipitor to the generic Zocor the only thing we can do? I'm also going to see if they can do the 90 day mail order thing because that should be cheaper as well.

According to my grandmother, since it is now January she will have to pay the annual deductible of $250 and then insurance will cover 80% up to $3,000. She says last year they hit the donut hole in August.

Polar Bear,

It depends on her plan...again...have grandma help her with her plan, which she can check online. If her plan is administered by Medco...the switch to Zocor will place her with brand name Zocor (its made by Merck which owns Medco). However...there are 3 generic statins...lovastatin, pravastatin & simvastatin - unless she has an unusual hyperlipidemia, she can change, but it will require a physician contact. The pharmacist can do that him/herself - I just fax the prescriber & request a change due to insurance coverage. But...you have to do your homework so you know what to ask for.

Now...ranitidine is otc - you can find it onsale thru many outlets. It is ALWAYS more expensive for me to dispense than for a pt to buy (unless its a Medicaid pt).

Zyrtec is very expensive - on every plan. Has she tried loratadine for her allergies? That is otc also. There are very real differences between these...so if she says it doesn't work, it doesn't. That has to do with how tightly the histamine blocker binds to the receptor & how easily it gets "bumped" off - they are competetive inhibitors. However, another trial of loratadine might be worthwhile. Few of these are ever on any plan...they are considered "lifestyle" drugs.

What is the hydroxyzine for???? Altho its an extremely inexpensive drug (its already a generic)...depending on what she takes it for.....sedation, itching, psych....she may or may not be able to switch to diphenhydramine - again....just generic Benadryl - otc. However, it too hard to tell if that would be appropriate without knowing why the physician is giving it.

The two expensive drugs you have here is Seroquel - with no alternative without a physician change & concomitant monitoring & Premarin. Most of my pts are off Premarin, but again...this is very personal. Some pts just can't get weaned off. However...there are alternatives - altho not generically equivalent...her physician may be willing to change her from Premarin (which has & will never have a generic equivalent) to estradiol (which is generic Estrace). Estradiol is still expensive - all estrogen replacements are & some women will absolutely hold tight to their choices & she may be one of those. She may be willing to wean off her estrogen completely, but it may take months, depending on how long she's been on it & she may not be able to tolerate the mood changes...so that shouldn't be done without physicians approval either.

Your grandma is spot on about when she hit the donut hole - most my pts hit it about the end of Aug/beg of Sept & started coming out Dec 10. With the new limits.....she won't come out until Dec 25 or so.

Anyway...have grandma go WITH her to the pharmacist (remember...we can't talk to grandma unless we have the release from her sister) & have him/her help with these changes & what other Oregon state options she has. Have grandma also scour ads for sales on the otc products - Costco, Walmart, Target will periodically place the otc items on sale...so she can get large quantities for a sale price.

Good luck again!

 

[ntubebate]

1977, said what I would say in a nice nustshell. I would just perhaps push more to D/C the Premarin, switch the statin and try my best to find a low dose of a true typical antipsychotic that would work for her.

Makes me wonder if a good ol' shot of Prolixin might help her.

ntubebate

 

[ntubebate]

Backing up here....

Don't the Seroquel drug reps say that until you exceed 200mgs you don't get antipsychotic activity?

I swear mine did one time.

ntubebate

 

[ntubebate]

Oh,
and a month of Loratidine is $4 at Wal-Mart.

And yes, I have a chart of Wal-Marts drug plan plainly posted for me to refrence 🙂

ntubebate