The end of the year is always an interesting time in the pharmacy. Some patients are trying to hold off until the next calendar year when they will be out of the coverage gap while others are trying to squeeze in every refill possible because they are beyond the gap or their insurance is changing or co-pays are going up next year.The ones that are trying to hold off are a particular challenge because they often put their health at risk by skipping doses or even entire weeks of medication. We strive to find solutions for these folks, but I fear that much of this behavior flies under the radar and we simply don’t know it is happening. We use partial fills when possible and try to find manufacturers’ discount cards for the more expensive brand name drugs. (see several previous blog posts) Unfortunately, our tool of a Congress has made it illegal to offer these discounts to people that are Medicare eligible. Not even enrolled patients, mind you, “eligible” patients. So even if you opted out of coverage you still cannot take advantage of these discounts! Our Senators and Representatives have no such restrictions, of course, enjoying the best health care coverage possible, on our dime.

So, yes, we have found some of our patients reducing their insulin dosage or simply doing without. Scary. Others forego blood pressure drugs, or even heart meds. It is quite common for people to use a variety of ill-conceived strategies to stretch their supply of medication. Their interactions with their insurance companies must be quite interesting.

One of our patients was recently approved for Enbrel and since he was past the coverage gap and into “catastrophic” coverage his co-pay was only $200. This persuasive and persistent patient was able to convince his Medicare part D plan that he was going on vacation in early January and got approved for a “vacation override” for another 4 weeks of Enbrel. Score! Most patients are not so lucky, each claim that we try to squeeze in before the end of the year is often rejected with a “refill too soon” message that indicates the date it may be filled. There is no easy way around this.

Another patient, with a Health Savings Account (HSA) thought it would be clever to refill all his inhalers, nasal sprays, and anything dispensed in its original container so that he could charge it to his HSA and then return them all for cash. Dude, that’s genius! Luckily, he asked about our return policy before actually proceeding with this scam. Federal law does not allow returns of medication, regardless of packaging, nor would we participate in this attempt at fraud. Dude, you’re busted!

Most of our chronic pain patients understand our guidelines and will not even ask about early fills. We did get a few however who questioned our calendar math, trying to get a fresh supply of oxycodone before the New Year. We are merciless and will not fill schedule 2 Rxs until there is 90% utilization of the previous Rx from the date picked up (not date filled, that may differ). We only had a handful that tried to push the issue. Being closed on Christmas and New Year’s day we often had to point out that even if Christmas was day 27 of 30 (90%), on the day after they should still have 2 days of medication remaining. Patients that continue press this issue end up with us taking a closer look at their utilization over a longer span of time than one month. We cannot be too careful when close to 100 people per day are dying from opioid overdose! Patient education and counseling becomes critical in these situations.

There are also a number of patients that have prescriptions that can be filled before the end of the year that will wait in our “ready” bins until the new year because the patients do not have the funds to pay their co-pays. This gives them about two weeks to come and pick up their meds.

I write this on New Year’s eve and I will tell you that next week will be even more fun as we deal with huge (or is that “yuge” now?) numbers of our patients having new insurance coverage and a fair number of them with no new insurance card, or changes in coverage and co-pays that they did not expect. It is one of the most challenging weeks in a retail pharmacy. Believe me!

Here is a chart from Kaiser that illustrates 2017 Medicare part D coverage:

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