Sensipar Bundle

[Tío Riñon]

During clinic this week, my dietitian presented me with the new option to get Sensipar for free starting this summer.  It is now supposed to be part of the bundle through Medicare (CMS).  I was told that I had the option of getting it through DaVita's pharmacy (which I dislike for a variety of reasons).  However, upon closer review of the document that I'm supposed to sign, it states that I either get it from them otherwise I cannot get it from any other pharmacy.  Here is the text of the document:

You have been identified as a bundle-eligible patient with a prescription for Sensipar® (Cinacalcet). DaVita will soon provide this medication as part of your dialysis treatment costs and will use DaVita’s preferred pharmacy, DaVita Rx.

What You Need to Know
• Sensipar® coverage will soon be included as part of your dialysis treatment costs (Medicare Part B), making this medication part of the CMS Bundle.
• Once the CMS Bundle goes into effect outside pharmacies will be unable to fill your prescription due to guidance from Centers for Medicare and Medicaid Services (CMS).
• When prescribed, your dialysis facility will provide you with this medication (Sensipar®) through DaVita Rx.

How is this being managed at other dialysis facilities (e.g. Frensenius and independent centers)?  Where is my option?  Get it from them or do without? 

Free is good, but I tire of being micromanaged or controlled by DaVita.  Besides, I like my local pharmacists and this means s/he loses out selling me this product.

What do others think of this process? 

[smartcookie]

I find it odd that you cannot get it at another pharmacy.  There are several "bundles" that Medicare dictates, one being a dialysis bundle for treatment meds, mostly.  I like that Sensipar is being added to the bundle because so many patients who do not have Medicaid in the US cannot afford it without prescription assistance.  With other bundles, you can get it at any pharmacy, you just need to tell them that it goes under your Part B instead of D.  At least, that has been my experience. 

I have not had any feedback from my company yet about Sensipar, only that it is going into the bundle this summer. 

[Rerun]

I wish Zach was still with us.  He would find out.

 

[Charlie B53]

As I understand it;

CMS Rules effective 1 Jan 2016 the Dialysis Clinic is REQUIRED to supply specific renal medications as part of the bundled Medicare payment.

The DCI Clinic the VA sent me to then start providing me with furosimide and (Qwap, I forget the other name) one of the Vitamin D's.  Since I had to switch to Hemo and thus change to my local Fresenius, they say they do NOT provide any medication to take home, only those injected during treatment.  Not really a problem for me, the VA immediately wrote and provided me with the furosimide. That Vit D the Clinic and I had a duscussion.  What happened it the Fresenius Pharmacy called me asking if I had "Other'' insurance they could bill for the med, otherwise they would not be able to provide it.

I need to send a note to CMS about this, stir the crock pot a bit.

So it seems that with the high cost of Sensipar, CMS is now requiring the treating Clinic to now provide that also.  This will save me the cost of my co-pay at the VA Pharmacy as well.

I am going to have to look up CMS for an email address where/whom to notify about prescription meds.

The statement your clinic is asking you to sign does NOT mean you have to get ALL of your meds from them, ONLY that one they are required to supply due to CMS Rules.

This change should save a number of people the higher co-pays they are facing.  I don't doubt there are a number of people skipping many meds due to those co-pays.  Living on Social Security ain't easy, especially for those of us that are used to earning far more working than what we are now forced to make do with.  Got to save every dime we can squeeze out everywhere just to enable us to eat Ramen the last week of every month, (almost).

[Rerun]

Why do we have to sign that?  Is it free NOW but soon we have to buy it and then we can only buy it from them.... because we signed?

Don't trust them.

[Tío Riñon]

I haven't signed anything yet.  DaVita is always trying to require their patients to sign documents waiving responsibility for something or stating that you promise that you have used the item provided for dialysis treatment (as though we are going to sell it on the black market or some such silliness).  As always, I told my clinic that I would need to review the paperwork and get back to them  (instead of just signing immediately as they hope).

I want to get the lay of the land and see what is happening outside the world of DaVita before agreeing to anything.  Thanks to those of you who have posted information. 

Charlie B53:  I agree with your point that this can prove beneficial to those who struggle to fund their co-pay or the full cost of the medication.  Nevertheless, I don't like a for profit business trying to manipulate me and other patients to make more money off of us (one of the options is to have all of your prescriptions handled by their pharmacy).  I do understand that I can limit them to only giving me Sensipar, but personally, I like to oversee my own treatment and DaVita is constantly trying to take it away.  The agreement states that I understand/agree that if I don't get the medication from them, I will be responsible for 100% of the cost.  My secondary insurance covers my prescription costs (not Medicare), but it sounds like with this new policy that I must comply or pay the full amount.  I don't think my insurance can/will cover the cost after this summer...at least that is it sounds like to me.  So much for freedom of choice.

Rerun:  The medication ISN'T free right now.  Patients must pay for the prescription.  That will change this summer due to Medicare rules when clinics will provide it for free as long as you sign some agreement, from what I understand. 

[Charlie B53]

CMS Rules state the treating Clinic has the responsibility to provide certain medications and submit billing for the weekly dosage to CMS for reimbursment at the contracted rate. 
For now there is a very short list of medications as there entire list is not due for implementation until 2025.  IIRC.

The Patient will NOT have to pay anything for these supplied meds, nor can the Clinic bill your other insurance.

My Fresenius clinic is supposed to supply certain meds, I have given them a list.  Their pharmacy lady called me to ask if I had other insurance she could bill, otherwise she could NOT fill the scripts.  So this morning I brought copies of a couple of pages from the CMS Manual.  I already talked to the Nurse, she wants me to wait and talk to the Dr about it.

Medicare Claims Processing Manual, Chapt 8, 60.2.1.2  Pg 61 of the downloadable .pdf

Medicare Benefit Policy Manual, Chap 11, Pg 26, Para C of the downloadable .pdf

Dr should take these copies and sent them to their Pharmacy along with the prescriptions.

I love stirring the crock pot.

[Simon Dog]

Excellent work Charlie.

[Tío Riñon]

Very interesting CharlieB53!  Thanks for your efforts.  Can you provide the URL for the downloadable PDF?

[Charlie B53]

I didn't save either of the links.  I found them with a simple Google search using the name of the manual.

I still haven't found a good contact number or email address for CMS Complaints.  But I am looking.  Dr wasn't in today.  I am told now he will be in Monday.  Not sure if I will wait.   I makes me crazy when a person or a company, shuns their responsibility to provide goods and/or services.   Staff at the local clinic don't have anything to do with it.  Everyone is merely peons doing what they are told.  None has any say-so, this is higher than locals, this is at Corporate and/or Pharmacy Services.

[smartcookie]

A Sensipar rep told our dietician that Sensipar is going to be approved "soon" for IV use.  That would cut the need for pill form Sensipar for in-center hemodialysis patients.  The dose will be high enough that it will cover the days that the patient is not at dialysis.  However, soon could be a couple years.  The IV Sensipar would be free to the patient as Medicare would cover it just like Micera or Heparin.  The doctor can then look at the patient's labs and change dosages more easily, as well. 

[iolaire]

My davita center had me sign the sensapar bundle via davita pharmacy in July paperwork.

Plus amgen has approval on a sensapar like iv med which I will be started on in April (at no cost) since it's good for high calcium and high pth patients. I feel like it's a test by the nephrologists group that owns the center I'm in (and a few others).  I'll need to go off sensapar for a few weeks before starting on the iv meds.  Asked about what I should do well traveling and in the short term I'll probably just skip the meds then.   It didn't feel like this test was to certify the drug as there was nothing to sign. It's removed by dialysis so would be given just prior to rense back.   

[Rerun]

When I start Prolia they want me to have high calcium. 

[Charlie B53]

I've been taking 60 MG Sensipar daily for a long time without a problem.  (Knock on wood). Yesterday I was told to increase to 90 as my numbers are going the wrong way.  Will see how they are next month.

[iolaire]

I'd be interested to know what the bundle payment financing is. My Aetna speciality pharmacy cost for 30 mil day is about $760. Is Medicare reimbursing that much or did they get the cost down some how.

[smartcookie]

I'm sure Medicare has a lower reimbursement rate.  They will write off some of the cost and then pay at their rate.  That is how Medicare does business. 

[Rerun]

The dietitian finally came around having people "sign" the waiver that DaVita will provide the Sensipar and we can't buy it any where else.  I wouldn't sign.  I said it was "Communist"   She rolled her eyes and left me alone.  I'll probably get black balled and kicked out.  Oh well.

  

[Alifeller]

you know... I'm not really aware of how they are related to each other but I tell you this: everything that can potentially be helpful must be tried. So in the end I hope that it WILL help you... like for example I now am trying Humatrope hoping it would help me recover faster from my back injury that I have now.

[Charlie B53]

My Fresenius clinic doesn't even want to give me the bottle of the Vit D, they give me two pills at every treatment.

No way are they going to give me any Sensipar.  Or anything else like my old DCI Clinic did.

[Simon Dog]

My Fresenius clinic doesn't even want to give me the bottle of the Vit D, they give me two pills at every treatment.

No way are they going to give me any Sensipar.  Or anything else like my old DCI Clinic did.

If it is in the bundle, they will not have a choice once you are on Mediscare, though you may have to be a bit assertive.

[Michael Murphy]

I think CMS may be making a end run around the part d  requirement that all drug costs are at full list price.  By moving drugs to the bundle which is part b the list price requirement is lifted and CMS can negotiate a lower payment.

[Charlie B53]

I've been on Medicare since I was forced to medically retire back in '08.   VA has been taking care of me since I was forced out of the Army in '75.

Fresenius has learned they can fax my VA Dr with a script, labs and chart notes, and the VA will issue me meds, which Fresenius SHOULD be issuing.

I need to find a list of meds published by CMS, then I could rightfully stir up the crock pot.

[iolaire]

This week I started on the IV replacement for Sensipar this week.  Its given during the rinse back.  So far no complaints, they will do labs on Monday to see how it does.  It seems the main side effect is to lower calcium and that generates other side effects like risk of falls.

[smartcookie]

I know Sensipar is intended to lower PTH, phosphorus and calcium, so I assume the IV one does that, as well.

[Michael Murphy]

By moving the drug to the bundle they increase compliance and make the drug easier to control by bypassing the patient and putting it under medical control.  Currently I ignore my hemoglobin results since my doctor is responsible for setting the drug regimen that takes care of my hemoglobin levels.