Opuscula Patient welfare Vs. AvMed profit

THIS IS ALL ABOUT what I perceive as a way for AvMed to increase its profits at the expense of its subscribers – its raison d’être.

For 2017, AvMed raised the “tier” – the level that determines the subscriber’s copay for a specific prescription – for one of my medications from Tier 2 – copay $7 – to Tier 4 – copay $75. The drug, Fenofibrate, has been on the market for several years and replaced, for me, Omega 3 which, like Finofibrate, AvMed jumped from Tier 2 to Tier 4 for 2016.

Sharon Robison, Manager, AvMed Medicare Member Engagement Center - no address included in her communication – informed me by mail that I could avoid a $75 copay for Fenofibrate by having my Primary Care Physician (PCP) prescribe Gemfibrozil instead. Gemfibrozal is Tier 2; the copay is $7.

I checked with my pharmacy and found out the full retail price for Fenofibrate is LESS THAN the AvMed copay – and that’s sans coupons, discounts, or drug discount cards. We are in the final throes of the 2016 presidential election disaster – no matter who wins, America loses – and my level of skepticism on all things is high; my suspicion is that AvMed is using Fenofibrate as a money maker – over and above what it gets from the government.

My pharmacist told me that Fenofibrate was developed several years ago to supplement Gemfibrozal because the later often was contra-indicated for people taking statins – which I do. Ms. Robison’s missive failed to apprise me of that little fact.

According to the National Institutes of Health (NIH),

Compared with gemfibrozil, fenofibrate produced significantly greater reductions in total cholesterol, LDL, and triglycerides and significantly greater increases in HDL. These changes were evident in patients receiving and not receiving concomitant statin therapy.

Between my pharmacist and the NIH, there appears no medical advantage for the patient to switch from fenofibrate to gemfibrozil; indeed this would be a step back.

It is interesting that of the several companies in the area that offer Medicare Advantage plans, one plan, HealthSun, rates Fenofibrate as a Tier 1; i.e., $0 copay. Others listed it as Tier 2 or Tier 3; only AvMed listed it in the $75 copay tier. AvMed’s copay was the same if the drug is purchased from a local pharmacy or via AvMed’s mail order partner.

The Center for Medicare and Medicaid Services generally sets guidelines for Medicare programs (which explains why most Advantage plans look pretty much alike). It apparently allows program owners, e.g., AvMed, Humana, and United Healthcare, flexibility with charges, most noticeably in re hospital stays and, to my chagrin, pharmacy copays.

There was a time when access to “my” specialists was critical, but that time has passed. I now can, albeit reluctantly, deal with PCP capitation.

Medicare programs are highly competitive. I can’t understand why AvMed would shoot itself in the wallet by what appears to be price gouging. I don’t sit in the AvMed board room so I’m not privy to management’s decision making processes, but if appearances count for anything . . .