Nurs Clin N Am 40 (2005) 5162Strategies for Acquiring AffordableMedications for Seniors

Kathy J. Morris, RN, MSN, ARNP, FNP-BCCouncil Bluffs Community Health Center, 300 West Broadway,

Suite 6, Council Bluffs, IA, 51503, USA

The story is not a new one; it appears on television and in newspapers,and the issue is repeatedly debated in state and national legislatures. Thenames and locations change, but the message remains the same: seniorcitizens cannot afford their medications [13]. Many seniors have evenreturned to work in effort to pay their monthly prescription bills. Manysenior citizens find themselves having to choose which medications they canafford to take, and others are unable to pay for both medication and food[4].

People are now living longer. The 2000 census recorded 35 million peopleover the age of 65, representing a 12% increase since 1990, and the censusbureau predicts this growth will continue [5]. The increasing population ofseniors is draining an already strained Medicare system. Health declineswith advancing age, and pharmaceutic care becomes an important part ofseniors health care management. Many seniors who cannot afford theirmedications simply do not take them. This causes complications for patientswith chronic health problems, and these complications then increaseemergency department and hospital visits, which in turn increases theMedicare burden. When evaluating long-term health costs of the seniorpopulation, it is important to consider that if compliance with medicationregimes promotes improved health in this group, making medicationsaffordable can prove to be cost-effective for the health care system [6].

Many patients over the age of 65 require three to five medications perday. This is a conservative estimate, as it is not unusual for some seniorswith multiple chronic illnesses to take ten or more daily medications. Thetotal annual medication bill for United States senior citizens averages$3 billion [7], and the cost of prescription drugs continues to increase,further compounding the problem. Between 1993 and1998, the cost of drugsincreased an was average of 40%, and this inflation is predicted to continueon an upward curve with no end in sight [4]. Although some individuals0029-6465/05/$ - see front matter 2005 Elsevier Inc. All rights reserved.doi:10.1016/j.cnur.2004.09.013 nursing.theclinics.com

52 MORRIShave prescription coverage, approximately 35% of senior citizens do not [8].Even seniors with prescription coverage see increases in their copayments asinsurance providers scramble to maintain benefits [9].

Data from the Health and Retirement Study indicates that over a 2-yearperiod, 2 million Medicare beneficiaries were noncompliant with medicationregimens as a result of drug costs [11]. Some undermedicated by skippingdoses or pill cutting, whereas others simply did not fill prescriptions [6,7].Medication noncompliance, especially in patients who have hypertension,diabetes, and heart disease, has been linked to an increase in complications,emergency department visits, and hospital admissions. Seniors who havemultiple medical problems and cannot afford their complete medicationregimen must choose which medication is the most important for them totake, often without understanding the implications of their decision. Thedemographic and socio-economic factors related to medication noncompli-ance that have been studied include: age, sex, extent of insurance coverage,and out-of-pocket costs [2]. All of these issues are relevant to the seniorpopulation. The majority of seniors are women who have greater financialburdens than men. Although many of these women had been in theworkforce, womens employer-based retirement plans were less likely tohave drug benefits than mens [12]. The ongoing noncompliance problemhas societal implications: the resulting increase in emergency departmentvisits and hospitalizations can eventually lead to more nursing homeplacements and consequently increase Medicare and Medicaid costs [13].Another important consideration is the decreased quality of life fornoncompliant seniors.

Some resources and options are available to help make the older patientsmonthly medication bill a little more affordable, but many seniors areunaware of or unable to locate these resources. Some senior citizens areafraid to tell their physicians [6] and children [10] that they cannot affordtheir medication, and therefore they either skip their medications or incura significant credit card debt. This article addresses the problem andidentifies the resources available to nurses and patients.

Legislative action

After years of work in the legislature, President Bush recently signed newMedicare legislation that addresses prescription drugs issues. The MedicarePrescription Drug, Improvement, and Modernization Act was signed intolaw in 2003. Although the new prescription benefit will not be completely ineffect until 2006, seniors may obtain a discount drug card during the interim.This card is intended to reduce the retail costs of medications from 10% to25% [14,15]. Additionally, seniors with lower income (ie, $12,124 for singlesand $16,363 for married couples in 2004) will qualify for an additional $600credit on their prescription card [16]. By paying a premium of approximately

53ACQUIRING AFFORDABLE MEDICATIONS FOR SENIORS$35, Medicare beneficiaries may opt to enroll in a plan that covers prescrip-tion drugs. The plans offered may differ, but all have common character-istics. For example, current plans call for the beneficiary to pay the first $250of prescription drugs cost, which is considered a deductible. Medicare willthen pay 75% of drugs costs between $250 and $2,250, while the senior paysthe other 25%. When the $2,250 limit is reached, the senior pays 100% ofthe drug costs until the $3,600 out-of-pocket spending limit is reached. Afterthat $3,600 limit is reached, Medicare will pay 95% of prescription drugcosts. Different plans may include further options to help pay the out-of-pocket expenses [17].

The dilemma facing senior citizens has not gone unnoticed at the statelevel. Maine recently initiated a prescription card program for its citizens.The program is not limited to seniors, but is based on income. Enrollmentbegan in summer 2004, with eligibility based on the federal poverty levels.Maine is not the only state addressing the problem. Twenty-five states havesome type of plan in place for prescription drug assistance (Table 1) [1821].The American Association of Retired Persons (AARP) also provides a listof state-sponsored prescription drug discount programs on their Web site[22].

Legislators in some of the northern Midwestern states, including Illinois,Maine, and Minnesota, are endorsing legalization that would permitimportation of lower-cost medications from Canada, claiming that thelower-cost drugs could then be used for a state-supported drug program forseniors. Some states attempt to assist seniors by providing Web sites whereprescription medications can be ordered from Canada, or even sponsor bustrips to Canada to enable seniors to make over-the-border medicationpurchases [23].

The FDA and several pharmaceutical companies are working to stop theimportation of prescription medications. The FDA is taking action againstcompanies that help seniors buy Canadian drugs over the internet, UnitedStates Customs agencies are confiscating imported medications, andpharmaceutical companies are threatening to stop shipments to Canadianpharmacies unless sales to United States seniors are discontinued. Althougha bipartisan bill was introduced in the Senate to prevent drug companiesfrom cutting off supplies to Canadian pharmacies that sell to Americanseniors [24], it was still illegal to import drugs from other countries as of fall2004 [18,20,21].

Generic medications

One of the most common methods of controlling medication costs is theuse of generic medications. As drug costs continue to climb, privateinsurance companies and Medicaid drug programs have been evaluating theuse of generic medications. In 2000, a study evaluating the use of generics in

Table 1

State sponsore

State

Cost to

join Information

California None HICAP

800-434-0222

Connecticut $25/y Department of

Social Services

800-423-5026

Delaware

opay

None Division of Social

Services

800-996-9969

Florida Prescr

Assistance P

for Seniors

None Agency for Health

Care Administration

800-963-5337

Florida Medic

Prescription

Discount Pr

None Agency for Health

Care Administration

800-963-5337

Illinois

ay

$5$25 Department of

Revenue

800-624-2459

Indiana None HoosieRX

866-267-4679

Iowa $20/y Iowa Priority

Prescription Savings

Program

866-282-5817

54

MORRISd prescription drug discount programs

Qualifications

Income

restrictions Plan

Medicare beneficiaries None Discounts the

same as Med-Cal

Low income[65or disabled

Yes Most drugs 30-d

supply for $12

[65 or disabled Yes State pays 75% of drugcosts to $2500/y with $5 c

iption

rogram

[65 who are eligible forMedicare Savings

Program

Yes $80/mo of prescription

drugs with $10 copay

are

ogram

Medicare beneficiaries None Medicare card

receives discount

[65 or disabled Yes Restricted by income andmedications for specific

diseases with variable cop

[65 without drugcoverage

Yes Refunds on prescriptions

between $500$1000

annually

Medicare beneficiaries None Discount card varying

discounts on certain drugs

Kansas [67 eligible for Medicare Yes Reimbursement for 70% None Department of Aging785-368-7327

Mar $10/mo CareFirst

800-972-4612

Mas None Office of Elder

Affairs

800-243-4636

Mich $25 application

fee

Currently closed

except emergency

coverage

866-747-8444

Minn None Senior LinkAge Line

800-333-2433

Neva None Senior Rx

800-262-7726

New None New Hampshire

Prescription Drug

Discount

888-580-8902

New

Ph

As

an

None Department of Health

and Human Services

800-792-9745

New

Pr

None Department of Health

and Human Services

Nort None Department of Health

and Human Services

800-662-7030

Penn None Pennsylvania Department

of Aging

800-225-7223

(continued on next page)

55

ACQUIR

ING

AFFORDABLEMEDIC

ATIO

NSFOR

SENIO

RS

and without drug

coverage

out-of-pocket

cost, $1200/y cap

yland [65 Yes Discount card With copay

sachusetts [65 and somedisabled

Yes Deductible $2000$3000,

then 100% covered

igan Low income[65 Yes Most prescriptions covered,copay varies by income

esota [65 enrolled in stateMedicare supplement

Yes $35/mo out-of-pocket,

then covered 100%

da [62 Yes Copay with state payingup to $5000/y

Hampshire [65 None Discount card 15% offbrand-name, 40% generic

Jersey The

armaceutical

sistance to the Aged

d Disabled

[65 or disabled Yes Discount card with $5copay at participating

pharmacies

Jersey Senior Gold

escription Discount

[65 disabled Yes Discount cardwith $15 copay

h Carolina [65 Yes Discount cardwith maximum

sylvania PACENET [65 Yes $500 deductibleand copay

Table 1 (continue

State an

Cost to

join Information

Rhode Island RIP iscount card

saves 15%60%

None Department of

Elder Affairs

401-222-2880

South Carolina 00 deductible

and copay

None SILVERx CARE

877-239-5277

Vermont VHAP iscount card and copay None Vermont Health

Access

800-529-4060

Vermont VSCRIP edications for long-term

medical problems

None Vermont Health

Access

800-529-4060

Vermont

VSCRIPT Expa

iscount card Copay

41% per script

None Vermont Health

Access

800-529-4060

Wyoming pay limited to

3 drugs/mo

None Division of Family

Services

800-442-2766

Data from Ref

56

MORRISd)

Qualifications

Income

restrictions Pl

AE Low/moderate

income[65Yes D

Low income[65 Yes $5

Low income[65 Yes D

T [65 or disabled Yes M

nded

Moderate income[65 Yes D

All state residents Yes Co

s. [3033].

57ACQUIRING AFFORDABLE MEDICATIONS FOR SENIORS49 states identified a potential savings of $229 million over a 1-year period[25]. Many insurance companies now offer tiered copays, with a lower copayoffered to customers who use generic drugs [26]. The number of availablegeneric medications is rapidly increasing as many brand-name drugs havereached the end of their patents. Patent expirations were expected on morethan 100 brand-name drugs in 2003 [27].

Generic drugs have been mistrusted in the past, but it is important to notethat the FDA approves the bioequivalence of generic drugs. All but a fewgenerics provide therapeutic benefits identical to their brand-name counter-parts. In an attempt to promote patient confidence in generics, the FDAsupported a consumer information campaign in 2003, posting public serviceadvertisements on buses and in consumer magazines [28].

Major pharmaceutical companies have encouraged the distrust ofgenerics by misinforming physicians about the quality of these drugs.Combined with the free samples generously given to health care providers,this has promoted the use of brand-name drugs. A common practice bypharmaceutical companies is to introduce a new formulation or animproved version of the brand-name drug when the patent expires, whichencourages continued use of the brand-name drug. The cost of brand-namedrugs can be as high as four times the cost of the generic versions, but thisdepends on the available competition; if only one company is makinga generic drug, the cost of the two versions may not be much different[28,29].

Resources

Pharmaceutical companies are not insensitive to the needs of seniorcitizens. Many companies have discount cards that can be used at localpharmacies [3033]. Some programs offer a Web site where medications canbe ordered, and others allow medications to be mail-ordered. All of theprograms have income requirements for eligibility, most of which are basedon the poverty level (Table 2) [32,33]. Another option offered by somecompanies is the Medical Assistance Programs (MAP), where eligiblepatients submit the required paper work and prescriptions from their healthcare provider and receive a 3-month supply of their medication fora discounted price. The MAP programs are not widely advertised and areusually only available through direct contact with the pharmaceuticalcompany [32]. It is important for patients to understand that they need todiscuss these programs with their health care provider, and request writtenprescriptions and assistance with applications to take advantage of thebenefits. Patients may also request to have their medication changed toa brand that offers an assistance program. Financial status needs to bediscussed with health care providers so that medication costs can beconsidered when choosing regimens. Box 1 lists some internet sites that helpin finding patient assistance programs.

Table 2

Pharm

Comp Contact information

Eli L cription at

ing pharmacies

877-795-4559

www.lillyanswers.com

Glaxo vings on drugs at

ing pharmacies

888-672-6436

www.gsk.com

Nova 866-974-2273

www.NovartisCarePlan.comer prescription

discounts both

ust be used at

ing pharmacies

Pfizer ents my

e medicines

hysicians offices

888-717-6005

www.pfizerforliving.com

Pfizer ow the income

ve 37%50% off

sh price; Families

income level

ve 15%25%

e cash price

800-717-6005

www.pfizerforliving.com

Pfizer prescription at

ing pharmacies

800-717-6005

www.pfizerforliving.com

Mult iscounts at

ing pharmacies

s medications

800-865-7211

www.together-rx.comAbbo

Bri

Gla

Joh

D

58

MORRISaceutical company drug discount cards

any

Name of

program Income restrictions Plan

illy LillyAnswers

Card

$18,000/Individual

$24,000/Household

$12 per pres

participat

SmithKline Orange Card $26,000/Individual 30%40%sa

participat$35,000/Couple

ritis Together Rx Two levels: Two level:

1) $18,000/Individual 1) $12/mo p

$24,000/Couple 2) 25%40%

options m

participat

2) $24,000/Individual

$38,000/Couple

New Program Connection to

Card

$19,000/Individual

$31,000/Couple

Eligible pati

receive fre

at some p

New Program Pfriends $31,000/Individual Families bel

level recei

average ca

above the

may recei

off averag

$45,000/Couple

Share Card $18,000/Individual

$24,000/Couple

$15/mo per

participat

iple companies: Together Rx

Card

$28,000/Individual 20%40% d

participat

for variou

tt, AstraZeneca Aventis,

stol-Meyers Squibb,

xoSmithKline,

nson & Johnson, Novartis

$38,000/Couple

ata from Refs. [3033].

http://www. lillyanswers. comhttp://www. gsk. comhttp://www. NovartisCarePlan. comhttp://www. pfizerforliving. comhttp://www. pfizerforliving. comhttp://www. pfizerforliving. comhttp://www. together- rx. com

59ACQUIRING AFFORDABLE MEDICATIONS FOR SENIORSAARP is also an important resource and advocate for senior citizens. TheAARP Web sites provide updates on current legislation, and tips for health,finance, and travel. Seniors struggling with prescription costs should beencouraged to make contact with AARP [34,35].

Splitting pills

Splitting or cutting pills can also be an effective cost-savings method.Many pharmaceutical companies have level pricing, which means that evenwhen the strength of the medication increases, the cost does not. Therefore,sometimes 2-months worth of mediation can be purchased for the price ofa 1-month quantity by obtaining the higher strength of the medication andcutting the pills into lower-strength portions. Studies have shown thatpatients can save between $600 and $700 per year on specific medicationsusing this method. Some medications conducive to splitting are those forblood pressure, cholesterol, and depression [36].

There are some important factors to consider when using this method toreduce costs. For example, not every pill or tablet should be split. Tabletsthat have been manufactured with scored lines are usually safe to split, butcapsules or enteric-coated tablets should not be split or cut. A study on

Box 1. Internet resources for patient assistance programs

http://www.canadapharmacy.com: Canadian mail orderpharmacy

http://www.needymeds.com: Free resource that searchespharmaceutical companies for drugs needed

http://www.rxassist.org: A site for health care providerssupported through Robert Wood Johnson Foundation

http://www.medicare.gov/Prescription/Home.asp: Medicarewebsite that identifies drug assistance programs and state- andcommunity-based programs

http://www.va.gov/vbs/health or http://www.tricare.osd.mil/retirees: Site for veterans, military retired, and widowedspouses

http://www.freemedicineprogram.com: Helps consumers enrollin medication assistance programs

http://www.BenefitsCheckUp.org: National Council of Aging sitelisting state-funded pharmacies and company-sponsoredassistance programs

http://www.ncsl.org/programs/health/drugs340b.htm:Community Health Centers and other organizations that haveaccess to low cost medications

http://www.canadapharmacy.comhttp://www.needymeds.comhttp://www.rxassist.orghttp://www.medicare.gov/Prescription/Home.asphttp://www.va.gov/vbs/healthhttp://www.tricare.osd.mil/retireeshttp://www.tricare.osd.mil/retireeshttp://www.freemedicineprogram.comhttp://www.BenefitsCheckUp.orghttp://www.ncsl.org/programs/health/drugs340b.htm

60 MORRISsplitting antidepressant medications found that 41% of the split pillsdeviated from their ideal weight by 10%. While this is acceptable with somemedications, it may greatly affect therapeutic levels in medications such asCoumadin and thyroid drugs [38]. Research conducted at StanfordUniversitys Center for Research and Disease Prevention found 48 pre-scription mediations that are safe to cut or split [37]. Providers must alsocarefully consider whether the patient is a good candidate to perform thetask. While pill splitters are available at most pharmacies, many patientswith arthritis, poor eyesight, or memory problems may be unable toaccomplish the task safely.

Seniors may be able to negotiate with their pharmacist to cut the pills foran additional charge and the pharmacist can check with the health careprovider for the appropriate dosage change. Pharmacists can be an excellentresource for questions regarding the appropriateness of splitting medi-cations. Senior citizens should be encouraged to discuss any questions abouttheir medications with their pharmacist [39].

Patient education and advocacy

Patients need to be assertive in requesting generics from health careproviders and pharmacists [40]. A study done by the Journal of theAmerican Pharmacy Association found that most consumers were inclinedto use generics, especially if their health care provider encouraged it. Seniorsneed to be educated not only on the value and safety of generics, but also ontheir rights to routinely request a generic substitution [29].

Many options for obtaining affordable medications are available toseniors, but a common problem is that senior citizens and the medicalcommunity are not aware of the existing resources. This presents anopportunity for nurses to act as patient advocates for senior citizens. Therole of the registered nurse as a patient advocate is not a new one; patientstrust nurses and the information provided by nurses. According to a pressrelease by the International Council of Nurses, 90% of the public worldwideexpressed confidence in nurses and acknowledged them as among the topprofessionals. The Council further stated that consumers trust the healtheducation information provided by nurses, even if it may be contrary toanother medical professionals [41].

Nurses have a responsibility to educate seniors on available healthresources. Patricia Benner described nurses role best when she said, Beinga good practitioner requires that we are moved by the patients plight andthat we respond to the patient as a person[42].

Nurses providing care in offices, clinics, hospitals, and homes can helpeducate senior citizens and health care providers about the availability ofresources that help with medication costs. In addition to contributing topatients financial well-being, these interventions can enhance health statusby promoting increased medication compliance.

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Strategies for acquiring affordable medications for seniorsLegislative actionGeneric medicationsResourcesSplitting pillsPatient education and advocacyReferences