The Not Entirely Complete Works of Peter Schulman

©2011 Peter Schulman

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Seven and a half equals thirty

Many years ago I heard Tom Lehrer’s New Math. Not only was it a delight, I took the math to heart. It enabled me to allay concerns of friends who were getting upset over the effects of using the decimal system (base ten).

I wrote a complete mathematical explanation of using different numeric bases for this but decided it would just be better to ask you to trust me on the math.

I have noticed young friends would freak out as they approached their thirtieth birthday. Older ones would develop a melancholy over turning fifty, or worse, sixty.

Worried about turning thirty? In base fifteen you’re really about to turn twenty (20 - 2 times 15 plus 0).

Does turning fifty get you down? In base twelve you’re only going to be 42 (4 times 12 - forty-eight - plus 2).

And sixty is merely 50 in base twelve (5 times 12).

I mention this because math was always intuitive to me. Trigonometry was so obvious I didn’t even bother to learn the formulae; I derived them during each test before using them to figure out the answers.

Math was always intuitive to me.

Until I picked a Medicare drug plan.

Allow me to lay out the basics of how prescription drugs work under Medicare. I’m going to leave some things out to make it easier to understand, although many will not find even the simplification very easy to understand.

The Donut Hole

You pay a monthly premium for your drug coverage. I cannot state it for an absolute fact, but the more you pay the more drugs are covered and the lower your copay for them. However, here is the part that can get expensive.

When the total cost of your drugs reaches $2840 your plan stops paying anything for a while. Some more expensive plans may extend that limit slightly, but I will stick with the basics.

After the total cost of the prescriptions reaches that amount you are in what has been called the donut hole where your prescription plan pays nothing until you have paid out $4550 not including your premiums.

To understand this, you need to understand what makes up the $2840 ceiling. The numbers below are used simply as an example

Your doctor prescribes a necessary drug for you: Makes-Me-Feel-Good (MMFG). Your copay is $25. You also get Pick-Me-Up (PMU) for which your copay is $20. You start the year with these prescriptions. Suddenly, in May, you go to your pharmacy and find the charge on your credit card is $710 because MMFG now costs you $430 and PMU $280.

You’ve been paying $45 a month in copays and that’s only $180 through April. How did the cost suddenly jump?

While you paid $45, the plan (and Medicare) paid the remaining $665. Between you the cost has always been $710 per month. Four months of $710 is $2840 and you have reached the donut hole.

Now you are going to have to spend $4550 before you get out of the donut hole and at $710 per month it’s going to take you a little over 6 1/3 months before Medicare starts chipping in again, right?

No.

The $4550 is the total you have to pay before you get out of the (donut) hole. But you’ve already paid $180. So you only have to spend an additional $4370 before you get help.

I know this sounds like a great offer. But wait, there’s more!

If you get a less expensive plan you will have higher copays. Instead of $45 for these two drugs you might have to pay $250 per month under a cheaper plan. So, you’re obviously better off buying the more expensive plan. It will save you more than $200 per month, right?

Not exactly.

For the same drugs you will enter the donut hole in May, at exactly the same time. Why? Because your $250 plus the plan’s $460 adds up to the exact same $710 per month. So now you’re still going to be paying all the costs for over 6 1/3 months before you get out of the hole, right?

Wrong.

By May you have paid $1000 in copays. It doesn’t matter whether you have spent it in the hole or before the hole. It counts toward your $4550 so you only have to pay an additional $3500 before you get out of the hole. In just under 5 months Medicare will be coming back to help you out.

If your plan has a yearly deductible you must pay before coverage kicks in, that deductible is also credited against the $4550.

Under this example your yearly prescriptions cost $8520. You are going to pay $4550 no matter when and in what amounts. When you get out of the hole you pay 5% and the plan pays 95%. So is the more expensive play the better option?

You pay $4550 and 5% thereafter on either plan. The more expensive plan is more expensive. It is not apparent initially, but if you are going to get beyond the donut hole, you might as well pay less per month unless the cheaper plan doesn’t cover drugs you are going to need.

But that’s not exactly right either. There’s more.

While you are in the donut hole, the drug’s manufacturer gives you a 50% discount. Not only are the drugs half price, you get credit for the full price towards your $4550.

You’ll need to do the math with your actual drugs, but in some circumstances you will pay less overall by getting the more expensive plan since you will have paid less to get to the donut hole and half the costs in the hole don’t really come out of your pocket (the discount is only 7% for generic drugs). You may wind up getting out of the hole with money you don’t actually spend instead of money you actually have spent for copays so it could be cheaper for you to get the more expensive plan.

I’m glad we have all that clear now.

Don’t blame me. I didn’t make this stuff up.

Searching for Adderall

I learned not all that many years ago that I was blessed with ADD. I worked with a coach and developed a drug regimen with my doctor. I learned how effective the drugs were when I decided one day to wait to take them until after my car was repaired.

As I sat in the waiting room I listened in to every conversation, to the show on television, to repair people coming in to discuss options and payments with the other customers, to the show on television, to every conversation, thought about whether I could get any work done at one of the two computers available to customers and listened to every conversation.

That was the first minute.

I would probably have screamed in frustration but I forgot to because I was listening in on every conversation, watching the show on television and remembering it seemed like a good time to scream in frustration or try to do some work on the computer.

What shocked me most about this experience is that I had spent close to sixty (base ten) years operating this way. Since I knew nothing else it seemed normal to me and I had gained a reasonable level of functionality despite the challenges I wasn’t aware I had.

I was determined I would never again voluntarily enter this state of chaos. And I did not until the day after my sixty-fifth birthday.

I had been taking 60mg (two 30mg capsules) of Adderall XR (or the generic when it was available because it was less expensive) daily. The copay for the brand drug was $25 and it had to be prescribed every month because it is a scheduled drug (there are laws regulating its distribution and use).

A mix up led to my March prescription having to be rewritten and I missed getting the April prescription under my old plan by four days as a result. I had enough left to get me to my birthday. I brought my card into the pharmacy and discovered Adderall XR was not covered at 30mg. But I got a discount for being a member of AARP so my monthly prescription would only be $426.

I couldn’t afford it so I passed. But wait, there’s more! I was taking something for my type 2 diabetes and the three-month copay would only be $330 (out of the actual cost of $990).

I contacted my provider, AARP, Nationwide, to see what I could do to make it just a bit less expensive. They told me not only did they not cover that prescription; there was no such thing as a 30mg extended release version of Adderall. The highest dosage they covered was 7.5mg and they had a limit of one per day.

I told the person I had taken the 30mg version that very day before talking to them, but I was assured no such thing was manufactured.

I checked the Medicare formulary online and it seemed to believe it did exist at the size I had been taking. So, I called back.

I reached a different person who confidently informed me there was no such thing as a 30mg size and, even it if did exist, they did not cover it. What do you say to someone who tells you with complete authority there is no such thing as gravity?

I called Medicare. The woman I spoke with checked the formulary and assured me the 30mg capsule was on it and did exist, not that I ever had any doubt. She contacted my benefits provider while I waited on the phone for her to explain to them they were mistaken.

That only proved how naïve I was. She told me they only covered the drug up to 7.5mg and I would need to request an exception. Of course, this meant I would be asking them to pay for a drug the existence of which they did not admit, so whether I got dispensation or not, they might well deny I had actually received it and refuse to pay.

Armed with the need to request an exception I called again. They couldn’t even consider it because it didn’t exist.

All of this had taken me past my birthday. I started my cold-turkey withdrawal on April 15 at the end of tax freaking season. I got out my last return on the 18th. Each day it was getting harder to concentrate.

By the 19th I was sleeping nearly fifteen hours a day. I felt like I had in college when I had mononucleosis. I made another attempt with my provider but got nowhere.

I spoke to my daughter-in-law on April 21, when I called to wish my son happy birthday. I may have expressed some frustration at my situation. She had been through some drug battles so she contacted my provider though they didn’t seem to provide anything but denials, a not unexpected response from an insurance company.

With me on the phone, she opened a chat session and the three of us discussed the matter and options for forty-five minutes. The conclusion of the representative was that the 30mg size was not covered, but it was covered under their more expensive plan even though they hadn’t yet admitted to its existence.

But their enrollment period didn’t open until much later in the year. I had been under the plan for less than half a month yet, somehow, had missed my window to cancel or change the plan except under very limited circumstances.

What about the fact that I had been enrolled outside the window of their enrollment plan? Perhaps.

So, reluctantly, I told my daughter-in-law to have the representative explore the possibility of getting into the more expensive plan.

After some time the rep said she thought she could do it. Could we hold on for a few minutes? Of course we could. Minutes later my daughter-in-law informed me the chat session had crashed from the company’s end.

I can hear what you’re saying. No, I’m not making this up.

Seven and a half equals thirty

I decided to call the provider myself and suck up the additional cost of the more expensive plan. I needed the Adderall XR.

I reached a nice woman and explained I wanted to switch to the other plan. We discussed whether they were likely to allow me to since I had missed the enrollment window.

How can you miss someplace you were never in?

I told her it was crucial that I switch because I needed to have a plan that covered 30mg Adderall XR.

She said, “It’s covered under the plan you have.”

“What?” I avoided, “What you talkin' about, Willis,” which would certainly have been appropriate in this situation.

“You’re covered.”

“But in my six prior contacts with your company, every one of them told me the highest dosage you cover is 7.5mg.”

“That is the 30mg.”

“Huh?”

“There are four ingredients. The 7.5 refers to one ingredient. Each of the others is also 7.5 which makes 30.”

“How are you the only person who works there who understands that?”

That’s how I learned that seven and a half equals thirty. This had clearly been too sophisticated for my mathematical skills.

But wait, there’s more!

She told me they only covered one of the 30mg capsules, formerly known as 7.5mg, per day. I would need to have my doctor contact the department that handled requests for exceptions. At my urging she agreed to talk to them first to explain to them that seven and a half equals thirty. I didn’t want to start all over again.

Bless her, she explained the concept to them and three-wayed us so they could tell me what I needed to do. Unfortunately, this was after my doctor had left for the week so I couldn’t have him contact them until April 25.

She said I would also have to have him request a change from tier 3 to tier 2 because none of the generic version was available. I had already tracked that down. The shortage had already lasted over six months and the contractual obligation required the manufacturer of the active ingredient to supply the brand maker first.

Why would there be a shortage? I went online to track this down.

It seems many people are interested in taking Adderall for the beneficial effects and not all of them get it through legitimate prescriptions. How could the DEA manage this problem?

Easy. They put a restriction on the manufacture of the active ingredient. That action has probably worked effectively to cut down on illegitimate use. It has also shut down production of the generic version and is now causing shortages of, take a wild guess, the 30mg size of the brand name.

But wait, there’s more!

Since I would have to wait four days for my doctor to be in and up to three more days for the company to respond, I went to my pharmacist to see what we could work out to get me the half of my prescription that was authorized.

I was in my ninth day of withdrawal and I could only stay awake for a few hours at a time. This was urgent.

My pharmacist entered the prescription and said the system had authorized the entire script. Because I have developed expertise in these matters, I barely managed to avoid saying, “That doesn’t seem right; could you check that again?”

So, they would only cover one, which equals two, of my 7.5mg prescription, which equals 30.

It was way too late to take the pills so I would wait until Saturday.

Does two equal one?

How much do I take? I’ve been off the medication long enough that 60mg may be too much. If I take them without eating I feel like I’m flying.

I wisely decided to take only one and wait two hours to evaluate the effect.

Two hours passed and I didn’t feel much of anything, so I took the second.

It seems two hours was not quite enough.

Never in my life have I been as focused as I have in the last two days. I managed an hour and a half of sleep and got up to a full, productive, focused day.

I got to sleep at nearly 5 AM Monday morning and managed to eke out six hours of sleep. I had succeeded in taking a fifteen minute nap Sunday afternoon. I took no medication Sunday and didn’t seem to lose a scintilla of focus. I didn’t even have to write myself notes to remember what I needed to get done.

Since I didn’t have to write notes I didn’t have to remember I wrote them or where I put them.

I have never had the level of focus I did over the weekend. I would zip off somewhere as always. But I snapped right back as if my distraction had been attached with a rubber band.

Had it not been for all these problems I would never have found out how focused it is possible to be.

I’ll have to work out the appropriate dosage with my doctor and adjust it as my body gets habituated to the dose.

But at least I’m out of the bizarre, random events attending this Wonderland.

I think.


This is not an exhaustive description of the Medicare drug coverage. I believe it covers the most important aspects. Feel free to ask questions but I may not have the answers. It is probably possible get most answers by starting at http://www.medicare.gov/. Having read the article above I’m sure you understand how easy that will be.