Блог Анкара

In This Chapter

^ Adjusting units for ease in computations

^ Changing from English to metric units and back again

^ Squaring off with square and cubic units

Any mathematical problems involve units of length, weight, volume, or money. You incorporate the units into your computations and

Then report them in the answers so the solution makes sense and is useful. Sometimes you’re confronted with problems that have two or more different units — such as feet and inches or pounds and ounces — and you have to make a decision as to which unit to use.

In this chapter, I offer suggestions on how to choose the unit or units and then how to work with the unit or units you’ve chosen. This chapter also covers the tricky conversions of square feet to square inches or cubic yards to cubic feet. And, of course, no discussion of units is complete without introducing meters and kilograms, so you get conversions involving metric and English measures.

Choosing the Best Measure

When a problem involves two different measures, you choose one or the other measure to work with and convert the unchosen measure to the unit you want so that they’re all the same. You may even decide to change measures when they’re already all the same — just because you think that another measure may work better.

Using miles instead of inches

A mile is much longer than an inch. In fact, there are 12 X 5,280 = 63,360 inches in 1 mile. If you’re measuring how far it is from one side of the desk to another, you’ll use inches. If you’re measuring how far it is from your home to your workplace, you’ll usually measure in miles.

The Problem: Train tracks are made of metal, and metal expands when it gets hot and shrinks when the weather is cold. When the tracks are put in place, a gap should be left between the adjacent tracks to allow for expansion. A metal track that’s 1 mile long expands with the heat and increases in length by 12 inches. There was no gap between the tracks, however, so it buckled in the middle and formed a V shape. (See Figure 3-1 for a picture of what the track looks like.) How high up did the track rise?

Figure 3-1

The train track expanded with the heat.

1 mile

^VLA/J! Two different measures are given: 1 mile and 12 inches. You can work with inches, and change the 1 mile to 63,360 inches, or you can work with miles

And write the 12 inches (1 foot) as 5 mile. The choice here is between

Using really large numbers and using fractions or decimals.

I choose to go with the fractions — to work with pieces of a mile. To find out how high the rise in the track is, I use the Pythagorean theorem (Chapter 18 is completely devoted to that theorem of Pythagoras) and one right triangle going halfway down the track. The bottom segment of the triangle is >2 Mile

Long, and the Hypotenuse (longest side) is >2 Mile plus 6 inches or 10 650 mile

Long. To solve for the rise, which I’ll represent with X, I solve the equation for X.

/1\2 /-« 1 \

‘ T ) + x2 = D 2 + Tn^ 2 2 10,560

This looks pretty nasty, but a scientific calculator makes short work of the problem, and you get

0.25 + X2. 0.2500947 X2 = 0.0000947 X = 0.009732

The height or rise of 0.009732 doesn’t seem like much, but, remember, this is in miles. Multiply by 5,280 feet and you get over 51 feet. Whoa! That’s quite a rise!

Working with square feet instead of square yards

When you buy carpeting, you usually buy it in square yards — 3 feet by 3 feet. But you probably bought your last tile floor in terms of a number of square feet.

The Problem: Using your yardstick, you measure the length of a room to be 6 yards and its width to be 5 yards. You plan on putting in 1-foot-square tiles. How many tiles will you need?

Before determining the area of the room, first change the yards to feet using 1 yard = 3 feet. So 6 yards is 6 x 3 = 18 feet. Five yards is 5 x 3 = 15 feet. A room that’s 18 feet by 15 feet is 18 x 15 = 270 square feet.

But what if you preferred finding the area in square yards, first, and then changing the area to square feet? The area of the room is 6 x 5 yards or 30 square yards. A square yard is equal to 9 square feet (3 feet x 3 feet). So multiply 30 x 9 to get 270 square feet.

Converting from One Measure to Another

When a problem contains more than one measure, you change everything to the same measure before doing the computing on the problem or solving the equation. You can’t add 6 inches to 4 feet and get 10 — you have to change the inches to feet or feet to inches. Knowing when to multiply and when to divide sometimes gets confusing, so your best bet is to write down the equivalence or change of units and then work from the equation.

Changing linear measures

First, here’s a list of some common equivalences used when working with lengths. I cover the English and metric equivalences later, in "Mixing It Up with Measures."

1 foot = 12 inches 1 yard = 3 feet 1 mile = 5,280 feet

The measure equivalences are used to convert from one measure to another. You may need to do more than one computation if there isn’t a direct equivalence between units — such as changing inches to yards or yards to miles.

The Problem: Cheryl has 48 rolls of satin ribbon, each containing 15 yards of ribbon. She plans to wrap packages to send overseas as gifts, and each package requires 30 inches of ribbon. How many packages can she wrap?

First, determine how many yards of ribbon are in those 48 rolls. Then change the yards to feet using 1 yard = 3 feet and the feet to inches using 1 foot = 12 inches. After you have the total number of inches, you can divide by 30 to get the number of packages that can be wrapped.

Multiplying 48 rolls x 15 yards you get 720 yards. Start with the equivalence involving yards and feet. To change 720 yards to feet, you multiply each side of the equation 1 yard = 3 feet by 720.

1 yard x 720

3 feet

X720

720 yards = 2,160 feet

You have 2,160 feet of ribbon. Change this to inches by using the equivalence involving feet and inches, 1 foot = 12 inches.

1 foot = 12 inches X 2,160 x 2,160 2,160 feet = 25,920 inches

That’s 25,920 inches of ribbon. Divide 25,920 by 30 to get 864 packages that Cheryl can wrap.

Adjusting area and volume

Area is a two-dimensional measure. You’re counting up how many squares — all the same size — fit into some flat region. You use area measures for floors in buildings and spaces in parking lots, as well as when you want to find out how much room there is in a backyard.

Volume is a three-dimensional measure and tells you how many cubes of a particular size fit into an object. Volume measures tell you about the inside of a refrigerator or the size of a cardboard carton.

IBE# 1 square foot = 144 square inches (12 inches X 12 inches)

1 square yard = 9 square feet (3 feet X 3 feet) 1 square mile = 640 acres

1 cubic foot = 1,728 cubic inches (12 inches X 12 inches X 12 inches) 1 cubic yard = 27 cubic feet (3 feet X 3 feet X 3 feet)

The Problem: Jimmy is going to play a prank on his dad and fill the refrigerator with ice cubes that are 1 inch on a side. The refrigerator can hold 6 cubic feet. How many ice cubes will Jimmy need?

Determine the number of cubic inches in 6 cubic feet by using the equivalence 1 cubic foot = 1,728 cubic inches and multiplying each side of the equation by 6.

1 cubic foot = 1,728 cubic inches

X 6 X 6

6 cubic feet = 10,368 cubic inches

That’s over 10,000 ice cubes. Jimmy had better rethink his plan. He’ll never get the ice cubes all stacked inside the refrigerator before they start melting — and he gets frostbite.

The Problem: Timothy bought 3,200 acres of land and intends to plant seedling trees on it. If each seedling requires an area of 9 square yards to grow properly, how many seedlings can he plan on his new acreage?

YUUV First, change the acres to square miles using 1 square mile = 640 acres and then the square miles to square feet. Determine how many square feet are in 9 square yards using 1 square yard = 9 square feet and dividing the result into the number of square feet in the acreage.

Changing the acres to square miles:

1 square mile = 640 acres X Square miles = 3,200 acres

Make a proportion of the equivalences, lining up the numbers and the X Exactly as they appear — opposite one another. Solve for X.

1 640

- = -

X 3,200 3,200 = 640X 3,200 640

Ran = 77777 X

640 640 5 = X

So 3,200 acres is equivalent to 5 square miles. Change the square miles to square feet by multiplying each side of the equation 1 square mile = 5,280 X 5,280 square feet by 5. You get that 5 square miles = 5,280 X 5,280 X 5 = 139,392,000 square feet.

Now find the number of square feet that each tree needs. If each seedling needs 9 square yards, use the equivalence that 1 square yard = 9 square feet and multiply each side of the equation by 9 to get 9 square yards = 81 square feet.

Now divide 139,392,000 square feet by 81 square feet to get the number of trees that will fit on the acreage. 139,392,000 divided by 81 = 1,720,888.89 trees. That’s a lot of seedlings.

Keeping It All in English Units

Many countries, including the United States, use primarily the English units of measurement. Pressure to change to metric hasn’t been strong enough, even though advocates have proposed changing to metric for over 40 years. The awkwardness of the English units is that they have all sorts of different numbers in their equivalences — as compared to the metric system where all the numbers are multiples of 10.

Comparing measures with unlikely equivalences

As disjointed as the English measurement system seems to be, it has a long tradition and some interesting and charming equivalences. Here are some more uncommon but historic measures, plus, to finish it off, a rate.

1 rod = 16>2 Feet 1 fathom = 6 feet 1 furlong = 220 yards 1 hand = 4 inches 1 league = 3 miles 1 pica = 12 points

1 mile per hour = 88 feet per minute = 1 -JF Feet per second

The Problem: The Preakness, one of the horse races in the Triple Crown, has a distance of 9.5 furlongs. How many miles is that?

Change the furlongs to yards using 1 furlong = 220 yards and the yards to feet using 1 yard = 3 feet. Then change the feet to miles using 1 mile = 5,280 feet. The race is 9.5 furlongs, so multiply 9.5 x 220 to get 2,090 yards. Multiply the number of yards by 3 to get the number of feet: 2,090 x 3 = 6,270. Now

A – a ,u Co7n( ,u Coon. , ,u u t I 6,270 .,

Divide the 6,270 feet by 5,280 to get the number of miles: r OOA = 1.1875 miles.

3 3 5,280

The decimal 0.1875 is equal to Tf, so the race is 1Tf.

16 16

To change a terminating decimal to its fractional equivalent, create a fraction that has all the digits to the right of the decimal point in the numerator and, in the denominator, a power of 10 that has as many zeros as there are digits in the numerator. Then reduce the fraction. For the decimal 0.1875, you write 1875 in the numerator and a 1 followed by four zeroes in the denominator.

0.1875 =

1875 10,000

Now reduce the fraction. You can first divide both numerator and denominator by 25 and then divide the resulting numerator and denominator by 25.

1875 75 10,000 400

_3_ 16

The Problem: A popular method for determining how far away a bolt of lightning has struck is to count the number of seconds between the lightning flash and the sound of the thunder. If sound travels at about 1,100 feet per second, and if it’s 6 seconds between the flash of lightning and the roar of the thunder, then how far away was the lightning strike in miles? And what is the speed of the sound in miles per hour?

First, determine how many feet the sound traveled by multiplying 1,100 feet by 6 to get 6,600 feet. Determine the number of miles using 1 mile = 5,280 feet. You divide 6,600 feet by 5,280 and you get 1.25 miles. According to what I was told, the number of seconds you count is the number of miles away. I don’t think I was told right.

Now, to the speed of sound in miles per hour, use the equivalence that 1 mile

Per hour is equal to 1 feet per second. The speed of sound is about 1,100

Feet per second. Write a proportion using these figures, letting the speed of sound in miles per hour be represented by X. Then solve for X.

1 mile per hour

1feet per second

X Miles per hour 1,100 feet per second

1 – _J5_ _ 22 _

X

1,100 15 (1H)0100) 1,500 750 11

- — ———

X 750

The speed of sound comes out to be about 750 miles per hour. This is a bit over the speed you usually see quoted. The textbooks say that the speed of sound is actually 1,088 feet per second at 32° F. I rounded the number up to 1,100 feet for ease in computation and assumed that the temperature during a thunderstorm would be a bit warmer than 32°F.

Working for a bar of gold

Television’s favorite billionaire is interviewing yet another group of potential employees. To keep from being told, "You’re fired!" the finalists have the following problem posed to them, and the first person to come up with the solution will not hear the dreaded words. The problem: You’ve hired someone to work for you for the

Next seven days. You must pay him VJ Of a bar of gold per day, but he requires a daily payment of VJ Of that bar of gold — no credit. It’s expensive to cut through a bar of gold, so what are the fewest number of cuts necessary to meet his requirements?

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Loving you a bushel and a peck

Volumes and weights take on some historically interesting values when working with equivalences. Do you buy your apples by the bushel, or is a peck all you need?

1 quart = 2 pints = 4 cups 1 gallon = 4 quarts = 32 gills 1 bushel = 4 pecks 1 pound = 16 ounces

1 ton = 2,000 pounds = 20 hundredweights

The Problem: According to a recent census, the typical American ate 13.8 pounds of turkey in a recent year. If this represents the total amount of turkey eaten at 12 different meals, then how many ounces of turkey were consumed at each meal?

VLAiV Change the number of pounds to ounces using 1 pound = 16 ounces by multiplying 16 X 13.8. Then divide the total number of ounces by 12. The product of 16 X 13.8 = 220.8 ounces. Divide 220.8 12 and you get 18.4 ounces per meal. That’s over a pound of turkey at a sitting!

The next problem involves a phenomenon of agriculture and requires that fruit growers adopt a good balance in their orchards. Consider an orchard where a certain number of apples are produced by each tree in an average year. If the number of trees in the orchard is increased, there’ll be more trees producing apples, but the crowding causes a reduction in the number of apples per tree. The balancing act for growers amounts to adding enough trees to increase production but not too many to decrease the production per tree by too much.

The Problem: An orchard contains 240 apple trees, which produce, on average, 2 bushels of apples per year. If the orchard manager increases the number of trees in the orchard by 60, she calculates that the amount of apples will be reduced by 1 peck per tree. If she goes ahead and plants those 60 additional trees, will the total crop be greater or smaller than the crop obtained from the original 240 trees?

^VLA* First, determine how many bushels of apples are produced by 240 apple trees by multiplying 240 x 2 = 480 bushels. Increasing the number of trees by 60 results in 300 apple trees. The production of 300 trees will be 2 bushels less 1 peck. Change pecks to bushels with 1 bushel = 4 pecks, giving you that 1 bushel is >4 Peck. Subtract >4 Bushel from 2 bushels, and the yield per tree

Will be 13 bushels. Multiply the number of trees by the new yield, and you 43

Get a total of 300 x 1-4 = 300 x 1.75 = 525 bushels. There’s an increase of 525 – 480 = 45 bushels of apples.

Mixing It Up with Measures

Most of the problems in this book use the English measures of length, volume, and weight. But metric measures are very important to know, because of the great incidence of foreign travel and trade with other countries that use metrics.

Matching metric with metric

The metric measurement system is extremely easy to use, because all the units and equivalents are powers of 10. A kilogram is 1,000 times as big as a gram, and a centimeter is 0.01 as big as a meter. The multiplication and division problems using metric measures are really a piece of cake. When you learn what the different prefixes stand for, you can navigate your way through the metric measurement system.

In the metric system, Kilo Means 1,000 times as much, Hecto Means 100 times as much, Deca Means 10 times as much, Deci Means K0 As much, Centi Means M™ As much, and Milli Means K000 As much.

The Problem: Stephen is the track manager at a race-car competition that’s 16 kilometers long. If he wants to put a spotter every 25 meters for the length of the race, then how many spotters will he need?

Change kilometers to meters using 1 kilometer = 1,000 meters and then divide the total number of meters by 25. The 16-kilometer race is 16 x 1,000 = 16,000 meters long. Divide 16,000 ■ 25 to get 640 spotters. That’s a lot of people!

The Problem: Stephanie works for a candy company and got permission to produce a piece of licorice that’s 12 meters long. She’s going to take the licorice to a party (just for the effect) and then divide it into individual pieces that are each 3 centimeters long. How many pieces of licorice will she have?

A centimeter is M™ Of a meter, so there are 100 centimeters in a meter. Multiply the 12 meters by 100, and you get 1,200 centimeters of licorice. Divide that total by 3, and Stephanie will have 400 pieces of candy.

Changing from metric to English

You’ve decided to go to Europe and you want to be sure that you order the right size beverage, know how far you’ll be traveling by car, and dress appropriately for the weather on any particular day. All these functions relate to changing from English units of measure to metric measure. Here are some of the more useful conversion equivalences you’ll need for your travels. For help with the temperatures, refer to Chapter 10 for conversions from Celsius to Fahrenheit and back again.

1 meter = 39.37 inches 1 kilometer = 0.621 mile 1 liter = 1.057 quarts 1 kilogram = 2.205 pounds

The Problem: You’re in Europe and about to take a day trip with a rented car and trusty map. You’re going to drive from your hotel to a famous cathedral. According to the map, the distance is 500 kilometers. How far is that in miles?

Use the equivalence 1 kilometer = 0.621 mile and multiply each side of the equation by 500. You get that 500 kilometers = 310.5 miles. That’s a pretty long trip, depending on what kinds of roads you’re going to find. You may want to check on an overnight stop.

The Problem: You’re driving along and notice that you’ll be needing fuel very soon. You spot a service station and pull over to buy fuel. The price on the sign is $2.25. You gulp after you realize that the price is for 1 liter of fuel. What is the price per gallon?

First, use the equivalence 1 liter = 1.057 quarts in a proportion with the price of 1 liter = $2.25 to determine how much the fuel costs per quart. Then you multiply that price by 4 because 1 gallon = 4 quarts.

1 liter 1.057 quarts

$2.25 1

2.25

X Dollars

1.057

X

2.25 (1.057) = 2.37825

The fuel is about $2.38 per quart. Multiply by four, and 2.37825 x 4 = 9.513 or about $9.51 per gallon. And you thought gas prices were bad in the United States!

Zz

X

Changing from English to metric

You’re on your European tour and you’ve brought some fabric samples to make curtains for your hostess and a recipe so you can cook up a thank-you dinner. Now you have the challenge of converting some of your measures into the measures of the country you’re visiting.

1 yard = 0.9144 meter 1 pound = 0.454 kilogram 1 cup = 0.2365 liter

Part of the challenge of cooking in another country is trying to find the ingredients that you’re used to working with at home. The other challenge comes when you need to measure those ingredients.

The Problem: Your recipe for lasagna calls for a 16-ounce jar (2 cups) of tomato sauce. You find a can of tomato puree (which you’ll have to spice up a bit), and the can contains % liter of puree. How many cans of the puree will you need to buy?

Create a proportion using 1 cup = 0.2365 liter and 2 cups = X Liters. Solve for X, Which will be the amount of tomato sauce you need in terms of liters. Then compare that amount to % or 0.75 liter.

1 cup 0.2365 liter

2 cups X Liters 1 0.2365

—— — -—-

— :

2

2 (0.2365)=0.473

The can contains 0.473 liter of tomato sauce. You need 0.75 liter. You’ll have to buy 2 cans, giving you 0.946 liter, and just save the extra for the next project. Good luck with the measuring part!

You’ve had way too good of a time on your trip to Europe. You’ve been avoiding getting on the scale to see if you’ve gained any weight, but you finally decide, the day before leaving for home, to get on the scale to see what the damage is. Omigosh! You’ve lost weight! You’ve lost a Lot Of weight! Then you realize that the scale is in kilograms.

The Problem: You weigh yourself on a metric scale and it says 68. How many pounds do you really weigh?

Use the equivalence 1 kilogram = 2.205 pounds and multiply each side of the equation by 68. You get that 68 kilograms = 149.9 or 150 pounds.

X

Chapter 4

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In This Chapter

► The development of massage therapy around the world

► Massage in today’s world

► Where massage is going

########•###••*#########•######••••####••«••##•##

7his chapter is supposed to extol the virtues of certain Greek physicians who developed massage a couple thousand years ago, and then it’s supposed to move on to the beginning of the twentieth century and talk about a certain Swedish man who was the father of modern western massage. And then the chapter should chronicle the… ZZZZZZZZZZ.

Was that the sound of your head smacking the table? Are you already getting so bored that you’re about to fling this book against the nearest wall in desperation? "Why can’t he tell me something fascinating and different?" you’re about to scream.

Okay, I can hear the psychic echoes of your potential screams, so this chapter is going to be a teeny bit different than the history chapters in most massage books, the ones that treat the chronology of massage like the dry academic stuff you find in history texts. What could be more unlike the vibrant flesh-and-bones reality of a subject as physical as massage?

Dramatic Moments in Massage History

For your benefit and edification, I’m going to recreate dramatic scenes from various important massage moments throughout history. Much of what follows has been garnished with a large dose of creative license, but rest assured that the information is based upon historical fact. Only the boring parts have been deleted to protect the innocent reader.

Shaman Bab — hands-on heater

Thousands of years ago, beneath the primeval rainforest canopies of the vast Amazon jungle in what is now part of Brazil, an old Shaman Squatted down by a river, twisting the leaves and stems of a hardy vine between his worn fingers. The shaman’s name was unintelligible to modern ears, so we’ll call him Bob. His fingers were working the powerful ayuhasca vine, which gave his people visions that helped them to heal. Bob boiled the leaves and stems of the vine in water with other plants, making a thick syrupy tea that he brought with him back into the village.

It was night. The rainforest canopy above was filled with the screeching sounds of life. Arranging the members of the tribe in a circle around a fire he had built, Bob gave them each sips of the tea, and they began to twirl and dance and sing traditional songs. Some of them, the ones who needed healing the most, fell into a trance, and Bob approached them.

As the others watched, Bob appeared to literally reach into each person’s body with his fingers. Then his fingers would flutter up toward the dark sky above the fire. He would touch them, brush them off, shake their limbs, staying in almost constant contact, and everyone could see (with the help of the ayuhasca) what Bob always saw — blurry spots where each person’s body was weak, demons of darkness clinging to a shoulder.

Although Bob used powerful herbs and jungle plants, his primary tool was touch. The difference between a casual touch from another tribe member and an intentional, focused touch from Bob was sometimes the difference between life and death. His touch healed, and everyone knew it.

The Tao of massage

The enigmatic Chinese word, Tao, Confuses many people. For one thing, why is the word spelled T-a-o when it’s pronounced Dow? And for another thing, what’s it supposed to mean anyway? Does it have anything to do with the New York Stock Exchange?

Many of you have heard of the Tao of Pooh Or the Tao of Physics Or the Tao of Flower Arranging, And if you ever read one of those far-out books on Eastern philosophy published in the 1970s — the kind printed on organic-oatmeal type paper — you probably remember the phrase, "The Tao that can be spoken of is not the true Tao." So then, how are you supposed to talk about it?

Regardless of the fact that you apparently can’t talk about the Tao, you can still talk about massage, which is exactly what an early Chinese Taoist did around 5,000 years ago. He wrote a book called the Con Fou of Tao-Tse (Cun Fooh of Dow Zee) that described the use of medicinal plants, exercises, and a

Great Greeks go nude

Imagine the Greek sun burning in a clear, blue sky. Below, in the outdoor Gymnaze’m, Dozens of naked athletes are exercising, each of them so tanned and muscled and healthy that they look like, well, Greek gods. Why naked, you ask? The word gymnasium itself comes from the Greek Gymnaze’m, Which means "to exercise naked," from Gymnos, Naked. Those fun-loving Greeks, I

At any rate, the sun’s beating down, all these naked Greeks are running around outdoing each other in feats of fitness, and old Asclepius is over there in the trainer’s corner, ready and

Waiting each time another Adonis comes running up with a torn Achilles tendon or sore lower back. The natural thing, of course, is to offer massage, along with other herbs and remedies. Supposedly, Asclepius became so proficient at this healing that he could even raise the dead. As a reward, Zeus struck him down with a thunderbolt and killed him.

This tale brings us to one of the very earliest philosophical lessons tied to the practice of massage: If you like to massage naked Greek athletes, try to keep it a secret.

System of massage for the treatment of disease. Because it was one of the first books ever written on any subject, the Con Fou Really goes to show you just how ancient and important this whole subject of massage is after all.

A Greek man tilth a mission

Asclepius (as-klee’-pee-uhs), son of Apollo, the Greek god of healing, may have been an actual Greek man who lived around 1200 B. C., but just as likely he was a mythological figment of the Greek imagination. At any rate, he was credited with being the first to combine exercise with massage. He also founded the world’s first gymnasium.

The Middle Ages

Nobody massaged anybody else (or was even allowed to touch much) during the Middle Ages, which almost wiped out western civilization. Luckily, a few hardy souls decided, despite vigorous opposition, to sneak off and touch each other in barns, stables, and other hidden places whenever possible, thus assuring the continuation of the human race and allowing people a chance to practice rudimentary massage techniques at the same time. Needless to say, the Middle Ages were Not A good time to be a professional massage therapist, and many of them suffered extreme deprivations. In fact, some say that a famous book by Victor Hugo, and the Broadway musical

The Hypocritical oath

You may wonder why doctors have to take a hypocritical oath after they finish medical school and before they begin practicing. After all, you trust your physician with your life; why would you want him or her to be a hypocrite?

The answer is simple. They’re not taking a hypocritical oath, but rather a Hippocratic Oath, which means that it was first uttered by none other than that great Greek physician himself, Hippocrates (460 – 380 B. C.). In the very first line of this oath, Hippocrates swears by Apollo and Asclepius to uphold the virtues of his healing art,

To not seduce women (or men) in the households he visits as a physician, and to abstain from mischief of all kinds.

Hippocrates also spoke about massage movements, saying that "hard rubbing binds, much rubbing causes parts to waste, and moderate rubbing makes them grow." He recommended massage for many conditions.

So, the man who penned the words that physicians around the world utter to this day was a believer in massage. Go figure.

Based upon it, are actually plagiarized versions of an original story about the lives of these wretched medieval massage practitioners. Sadly, the original manuscript has been lost, and the true origins of Les Massagerables Will forever remain a mystery.

The Swedish scenario

In most places you go in the western world today, when you ask for a massage, youTl receive one form or another of Swedish Massage. And so, you may ask, Why Is it called Swedish massage? Here are some of the typical answers people have given to that question:

People in Sweden were the only ones liberal enough to allow massage to be named after them.

The Swedish director Ingmar Bergman liked to receive massage after a hard day on the movie set, and so they named the technique after him.

Nobody knows why it’s called Swedish massage, but everyone agrees it sounds better than Lithuanian massage or Uruguayan massage.

Actually, Swedish massage is named after a Swedish physiologist and fencing master by the name of Per Henrik Ling (1776-1839), who developed a system of Medical Gymnastics that included the moves we now use in basic massage. He eventually became known as the father of physical therapy. The fact that his

Original system embraced massage is interesting because physical therapists in the modern world have to a large degree ostracized massage from their repertoire, and there is sometimes discord between them and massage therapists.

Decline of massage in the twentieth century

Due to the infighting amongst massage practitioners, and the sudden, powerful influence of technology in the medical world, massage faded from favor during the early and mid-1900s. Also, the earlier popularity of massage induced some people to try to make a profit from it illicitly. Around the turn of the century, several schools in Great Britain, for example, were turning out poorly trained practitioners, some of whom ended up acting as prostitutes, which was a big downfall for massage. Since the days of Hippocrates, and even further back into the ancient history of China and India, massage had been accepted as a healthy pastime by a sizeable number of people. Now, things were different.

Massaging Cain and Abel

Perhaps the discord in the massage world can be traced back to the pair of American brothers who were responsible for bringing massage to the United States from Sweden — Charles and George Taylor. The Taylor brothers shared similar interests, obviously; they both became doctors, both went to Europe to learn these new techniques, and they both wanted to spend their lives helping other people. But, as so often seems to happen when people go on a quest to help others, they just couldn’t seem to get along themselves.

Coming back to New York in the 1850s, they opened a clinic together, but within a year they dissolved it and went their own ways.

"It’s MKtechnique for helping other people feel better," said Charles, adjusting his bowler hat atop his head.

"No way, it’s Mine" Replied George, adjusting his identical bowler cap.

And thus started a problem that has persisted to this day, with various massage innovators and practitioners teaching that their way is the best way. George and Charles Taylor were the Cain and Abel of the modern massage world. And, even though massage as a whole is a glorious way to help people feel better on many levels, it has been broken up into sects, with the proponents of certain techniques loudly proclaiming theirs as the best. This book, I hope, will help you cut through all that so that you can gain an appreciation for massage as a whole.

Freud and massage

Sigmund Freud, the inventor of modern psychoanalysis, used massage with his patients. Early on, when Freud wanted to calm and reassure his clients that he was on their side, he used massage maneuvers primarily on their hands. Unfortunately, Freud left massage behind as he further developed his psychoanalytic techniques, perhaps out of a fear that he wouldn’t be

Able to know what was really working, talking or touching. But he was greatly in favor of it from the start. In the modern world, many psychologists are rediscovering the power of massage and incorporating it into their practice with body-centered psychotherapy and somatic therapies.

Throughout the mid-1900s, many massage therapists in the U. S. worked in a YMCA or a Turkish bath house and weren’t expected to do much more than pummel their victims (er, clients) with some extraordinarily vigorous maneuvers, usually meant to purge the recipient of excess alcohol and fatty acids ingested the night before. In fact, some spa towns, such as Hot Springs, Arkansas, had massage facilities that were open on Sunday mornings especially for this purpose. The upstanding men of the community came in early to have the effects of Saturday night’s revelry pounded and sweated out of them by hardy massage practitioners.

Hippies save massage from extinction

Overall, things weren’t going so well for massage in the United States. And the same was true, for the most part, in Europe. Only people with hangovers wanted massage. J3f course, on a worldwide level, massage in many areas still retained the same untainted prestige it had enjoyed for centuries. But even in the most remote areas there was a clamoring for things new — vibrating mas-sagers instead of actual massages, for instance — and as technological revolution swept the planet, it left people high and dry as far as contact goes.

The human species was literally getting out of touch.

As always, when society swings too far in one direction, a mounting momentum tends to bring it back toward equilibrium. Somewhere in the 1960s, people began to tire of the soulless sway of machines and technology in their lives, and they started to react against it. These revolutionaries were called hippies, or flower children, and they spread out from San Francisco to cover much of the world, toting with them tie-dyed T-shirts, prayer beads, big black vinyl discs called albums, and home made massage tables.

Keep in touch, Lorraine

The hippie movement brought people back into touch with themselves, as exemplified by the story of Lorraine, who, in 1968, couldn’t decide exactly what to do with her life and so went off in search of something new in California, like so many of her generation.

"I need to get in touch with myself," intoned Lorraine to anyone who asked her what she was doing. Perhaps she didn’t realize how precise her choice of words truly was.

Heading her faded yellow VW Bug west, with "Go Ask Alice" playing over and over again on the eight-track tape deck mounted under the dash, Lorraine kept driving and driving until she

Came to the remote spot on the winding highway south of Big Sur in California that so many people had told her about.

The place was called the Esalen Institute, and it was a mecca for consciousness-raising workshops, research into alternative health, superb massages and massage instruction, and just plain blissing out. People from all over the world came to Esalen to get back in touch, literally, with themselves and with life. Lorraine moved in, stayed for five years, and by the time she left she had found her calling in life and became a massage therapist.

Massage Today

Through the years, massage has had a serious, multiple-personality disorder, kind of like Sybil. Every time you look at it, you’re never sure exactly what you’re going to see. A Greek physician massaging athletes? A Swedish physiotherapist creating movements to help ease common suffering? A shaman purging evil spirits? A spiritual seeker sending healing vibrations through her fingers during an Esalen style massage at a spectacular seaside retreat?

So many choices

Massage is enjoying such a large renaissance right now, in fact, that at times the market may appear glutted with too many massage therapists. An alternative newspaper in Asheville, North Carolina, for instance, printed a cartoon summarizing the plight of that city’s abundance of highly trained, underemployed massage therapists. The cartoon showed an out-of-work therapist standing at a corner holding up a sign: "Will massage for food."

So where does that leave you as you head out the door today, tomorrow, or next week to go seeking your own massage experiences? Well, you certainly

Have a lot more choices, which I clarify in Chapter 9. You also have a lot more massage therapists to choose from — somewhere between 30,000 and 50,000 new massage therapists in the U. S. each year, for example. And France, which is not a huge country, has over 35,000 practicing Kines, Short for Kinesiothera-peut, Their term for massage/physical therapist. These practitioners are popular, partly because insurance has covered their services since 1974; people in France are used to receiving massage as part of their healthcare.

Although you do have more choices than ever, I think the assumption that we’re getting anywhere near a critical mass of massage practitioners in the world is mistaken. There are just too many people around these days to massage— over six billion of them as of August 1999 — and the population continues to expand rapidly.

What you can expect in terms of massage in the year 2000 and beyond is an ever-increasing number of choices, kind of like you find in those designer coffee shops. Whereas before the choice used to be simple — regular or decaf? — now you’re faced with an overwhelming array of mochas and frappes and lattes and on and on. This phenomenon has been termed the Starbuckizing of massage.

Touch research

To keep up with all the rapid changes and to document the effectiveness of massage in the midst of all these changes, somebody had to start some serious research into the matter, and that’s just what they do at the Touch Research Institute.

If you happen to live in South Florida, and you were to stroll down to the local medical center, you probably wouldn’t be too surprised to find some scientific studies being conducted in one of the buildings there. But you may be surprised to find that, instead of an operating room or a clinic, these studies are being conducted in softly lit chambers with flute music playing in the background. And the subjects, instead of undergoing cutting-edge medical technologies, are receiving the age-old techniques of massage therapy.

The Touch Research Institute was founded in Miami in 1992 to study the effects of touch on human beings. Whereas the senses of smell, hearing, sight, and taste all have had their institutes and studies for decades, poor little orphan touch was neglected until the 1990s.

Perhaps touch was neglected because it is just so obvious. When you think about it, nothing is Not Touch; your body is a large antenna feeling everything as it happens to you. The other senses all involve touch in one way or another, too; molecules of various kinds hit you in the taste buds, the optical nerves, the ear drums, and the nasal passages, which set off the sensations that make the senses work.

A massage pilgrimage to Esalen

The pioneering work done at Esalen helped keep massage alive and well after its decline in the early and mid-1900s, Esalen, located in Big Sur, a couple hours south of San Francisco, was founded by Michael Murphy in 1962, and some of the best massage teachers and researchers in the world have taught and worked there. The result of their efforts has been a shifting of the entire paradigm upon which massage is built. No longer simply a remedial form of "gymnastics" to restore movement and ease pain, massage has become a way to increase awareness and sometimes even access the spirit.

If you’re passionate about learning what massage can be on this spirit-enhancing level, you

May want to make a trip to this massage-mecca yourself. Wherever you are in the world, if you are a massage lover, making your own massage pilgrimage to Esalen will benefit your spirit!

Esalen’s location itself is spectacular, perched upon steep cliffs overhanging the Pacific Ocean, where hot springs flow from the mountainside directly into a series of pools adjacent to the massage area. {Esalen’s Web site is at Www. esalen. org,)

Nudity alert: Beware, Esalen is clothing optional, and nudity is common. Think of it as a great way to get used to viewing the grand masterpiece of the human body.

In 1998, two new Touch Research Institutes opened, one in the Philippines and one in France, which points toward a globalization of studies on massage. How can they get away with testing massage like that, you ask? How can people just lie around feeling good and then call it research? First of all, they don’t call it massage, but rather Tactile Kinesthetic Stimulation, Which, translated, means "massage that someone can receive a medical research grant for." And the studies include extensive psychological tests, blood analysis, double-blind tests (tests in which neither the participants nor the researchers know which subjects have a particular disease or condition and which don’t), and a large amount of paperwork. So it’s not just a big vacation.

Some of the studies that have been done at the Touch Research Institute include the following groups:

HIV patients: Serotonin and killer T-cells increased due to the massage.

^ Premature infants: Massaged infants gained weight more quickly and left the hospital an average of six days earlier than non-massaged infants, at an average savings of $3,000.

& Depressed teenage mothers: Massage helped them gain self-confidence and provided a way for them to connect with their infants.

W Children with post-traumatic shock syndrome after hurricane Andrew: Massage offered psychological reassurance that the world could be a safe place again.

^ Cancer patients: Researchers are still gathering data about how massage can help with this disease.

The Future of Massage

Many people are familiar with John Naisbitt’s book Megatrends, Which discusses the problems people face as society heads into an increasingly technological world. Naisbitt says that as people get more high-tech, they have to become equally High-touch As well. Massage, of course, is one obvious answer to this dilemma.

Following are examples of some high-touch trends that show every sign of continuing into the future as massage integrates more and more into society’s high-tech lifestyle:

■ Diplomacy: Massage therapists already travel around the world as

■ ambassadors of compassion. This trend will continue as hands-on tech -

■ niques evolve and cross-cultural communication develops further.

I Performance: More and more performers, athletes, and high-profile indi -

I Viduals will discover the value and relevance of massage. Every

■ professional sports team, for example, will have massage therapists on

■ staff (many do already), creating a trickle-down effect as fans and the

■ general public become increasingly aware of massage through the I Team’s example.

I Affordability: As the world gradually shifts from a manufacturing-based

I Economy to an information – and services-based economy, the demand

I For massage will continue to grow. Employers and insurance companies

■ will be increasingly willing to pay for massage services, which will benefit

■ the bottom line by reducing absenteeism, stress-related injury, and so on.

I Increased sophistication: Massage techniques (some of which have

I Been around for centuries) will become more and more sophisticated as

■ practitioners from various schools cross-train and add new skills to 1 Their repertoires.

Chapter 3

•••••••••••••••••••••••••••••••••••••••••••«

In This Chapter

^ Getting a grip on formulary fundamentals

^ Understanding plan limitations on some drugs

^ Obtaining the drugs you need when they’re not covered

^ Figuring out when drugs are covered by Part D or other parts of Medicare

7he whole point of Part D is to help people with Medicare get the prescription drugs they need to fight disease and maintain their health. The cost of meds under Part D, explained in Chapter 3, is only part of it. The other big concern is Coverage — that is, which drugs a Part D plan helps pay for. In particular, you want to know if your drugs are covered and how easily you can get them.

Chances are high that your drugs are covered in several plans available to you, or even in most of them. But you can’t just assume that all of your drugs are covered in Every Plan. That’s because Part D plans are allowed to choose which drugs they cover in any given year, within certain Medicare rules. Just as plans vary in their charges, so do they vary in the drugs they help pay for.

Another aspect of Part D coverage to be aware of is that any plan can require you to ask permission before it will cover certain drugs your doctor has prescribed. You may not encounter this hurdle — again, it all depends on the drugs you take and the plan you choose — but you should know that this obstacle exists and what to do if it happens.

In this chapter, I share how plans vary in their coverage of different drugs and how to find out which plans cover your meds. I also explain the ways that plans can restrict immediate access to some drugs and how to deal with this situation if it arises. I delve into the important role your doctor plays in how to get coverage for drugs that your plan doesn’t normally cover or restricts access to. Finally, I explain how the same drug may be covered under Part D, Part A (hospital care), or Part B (outpatient care) in different circumstances.

Finding Out about Formularies

Formulary Is a jargon word that becomes very familiar when you’re in Part D, because it directly affects your prescription drug coverage. A Formulary Is simply the list of specific drugs that each Part D plan has decided it will cover.

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If the drugs you take are on your plan’s formulary, the plan will pay its share of the costs during the initial and catastrophic phases of coverage (see Chapter 2 for an introduction to these phases). If any drug Isn’t On the formulary, you pay full price for that drug in Every Phase of coverage — in the initial coverage period and at the catastrophic level, as well as during the deductible period and in the doughnut hole — unless you can persuade the plan to cover it in your case, as explained in the later section "Requesting an exception with your doctor’s help."

As you can see, coverage is intimately entwined with cost. The difference in cost between a drug that’s on a plan’s formulary and that same drug when it isn’t on a plan’s formulary can amount to several hundred dollars. Consider this example for a drug prescribed to help people sleep when they’re in pain. The full price of this drug is the same in both Plan X and Plan Y. But Plan X, which covers the drug in the initial and catastrophic phases of coverage, charges $521 for it over the whole year. In contrast, Plan Y — which doesn’t cover the drug at all — charges $1,200 for it over the year. If my math’s right, that’s a difference of $679 for the identical drug!

Making sure that the drugs you need are on your chosen plan’s formulary is essential for another reason, too. If you fall into the doughnut hole (also known as the coverage gap; see Chapter 15), a drug that isn’t on the formulary Doesn’t Count toward your out-of-pocket limit that gets you out of the gap — unless, again, you’ve persuaded the plan to cover it for you.

So when you’re picking a Part D plan, both for cost reasons and because, darn it, you need these drugs for your health, your goal is to find a plan that covers all of your medications — or, failing that, almost all of them — on its formulary. (I explain how to find out which plans cover your drugs in Chapter 10.)

How many medications do Part D plans cover at any one time? The number varies a great deal among the plans, and some have many more than others. As a general indication, in 2008, the top ten plans (those with the greatest number of enrollees) averaged 2,285 distinct drugs on their formularies, according to an analysis by the health research group Avalere Health.

Despite this variation in the number of covered drugs, each Part D formulary must comply with Medicare rules in the following four areas:

F The drugs that plans must cover

F The drugs that Medicare doesn’t pay for

F The tricky issue of off-label drugs that are prescribed for unapproved treatments

F The rules on what plans can and can’t do when changing their formularies

I provide more info on each of these areas of regulation in the following sections. Later in this chapter I explain what you can do to get needed drugs that are affected by these conditions.

The drugs that Part D plans must cover

Medicare doesn’t require Part D plans to cover any individual prescription drug. But it does require plans to cover at least two in each class of medications. A Class Means all the similar drugs that are used to treat the same medical condition. Many plans cover more than two in a class.

For example, about half a dozen brand-name statins — drugs commonly used to counteract high cholesterol — are currently sold, as well as generic versions of some of these drugs. Many plans cover all the brand-name statins, and some don’t cover any. But plans that don’t have the brand-names on their formularies do cover at least two of the generic statins, which have the same active ingredients and are just as effective at less cost to you. (I cover generic drugs, and why it’s worth talking with your doctor about using them, in Chapter 16.)

Every plan must also cover "all or substantially all" drugs in each of the following six classes of medications:

F Anticancer drugs (used to halt or slow the growth of cancers)

F Anticonvulsants (used mainly to prevent epileptic seizures)

F Antidepressants (used to counteract depression and anxiety disorders)

F Antipsychotics (used to treat mental illnesses such as schizophrenia, mania, bipolar disorder, and other delusional conditions)

F HIV/AIDS drugs (used to block or slow HIV infection and treat symptoms and side effects)

F Immunosuppressants (used to prevent rejection of transplanted organs and tissues, immune system disorders, and some inflammatory diseases)

Medicare requires every Part D plan to cover pretty much all drugs in these categories due to the clinical problems that can occur when patients abruptly stop such medications or switch to others.

The drugs that Medicare doesn’t pay for

By law, Medicare doesn’t pay for certain kinds of drugs. This directive doesn’t mean Part D plans are prohibited from covering them — just that, if they do, Medicare won’t reimburse its share of the cost. So, although a few plans (typically those with higher premiums) may cover some of these drugs, most plans don’t cover any. The types of drugs excluded by Medicare are

F Barbiturates (used for seizures and anxiety, such as Amytal, Nembutal, Seconal, and so on)

F Benzodiazepines (used for anxiety and sleeping problems, such as Serepax, Valium, Xanax, and the like)

F Drugs sold over the counter (nonprescription medicines)

F Drugs used for anorexia, weight loss, or weight gain

F Drugs used for cosmetic reasons and hair growth

F Drugs used to promote fertility

F Drugs used to treat sexual or erectile dysfunction

F Medicines to treat cough or cold symptoms

F Prescription vitamins and mineral products

Sometimes Medicare pays for medications in these categories if they’re used for a "medically accepted" purpose. Here are a few examples:

F Drugs to help people stop smoking are excluded when bought over the counter, but accepted if prescribed by a doctor.

F Prescriptions for drugs used to counteract severe weight loss in AIDS patients are accepted because they’re medically necessary and not regarded as the usual weight-gain drugs.

F Prescriptions for drugs used to treat skin conditions, such as acne and psoriasis, are accepted because they’re not considered cosmetic.

F Cough medicines are accepted when prescribed to alleviate medical conditions such as asthma.

F Drugs normally used to treat sexual or erectile dysfunction (impotence) are allowed if prescribed for a different but approved use, such as the treatment of certain conditions affecting veins and arteries.

If you need any of these drugs for medically accepted reasons, you need to ask your doctor to file for an exception with your plan, as explained in the later section "Getting the Drugs You Need When They’re Restricted or Not Covered."

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The off-label uses for some drugs

When a doctor prescribes a drug Off label, She’s using that drug to treat a medical condition for which it hasn’t received official approval. The U. S. Food and Drug Administration (FDA) approves drugs and allows them into the market to treat specific illnesses. But if scientists find that a drug is also effective for another illness, doctors are legally free to prescribe it off label for the other illness, even if it hasn’t received FDA approval for that purpose.

This practice allows doctors to use their clinical judgment and is officially endorsed by the American Medical Association. In fact, it’s so common that hundreds of thousands of off-label prescriptions are written every year, especially for patients with cancer, chronic pain, and rare disorders.

Medicare law says simply that Part D plans may only cover drugs approved by the FDA. That’s very clear, and it’s meant as a safeguard to patients’ health. But what if a doctor prescribes a drug that’s both on a plan’s formulary And Is FDA-approved — but not for the condition prescribed? Can the plan cover it? Medicare regulations say that it can, but only if the off-label use is included in any of three medical Compendia (directories of drugs that list their usages).

The snag is that some time may elapse between medical research finding a new use for an existing drug and that usage being listed in the compendia. As a result, Part D plans are prohibited from covering drugs in this twilight zone, and patients who’ve used them effectively before joining Part D must either pay the cost themselves or do without. However, there’s one important exception. Under a recent change in Medicare law, Part D plans are allowed to use authoritative medical literature (as well as compendia listings) to justify off-label use — for anticancer drugs alone — starting January 1, 2009. (The Medicare Rights Center, an advocacy group, is suing the federal government to have the ban removed for all off-label uses.)

The rules of formulary changes

Every plan is allowed to take drugs off its formulary or add new ones to it at any time, subject to Medicare approval. If you’re in a plan that discontinues coverage for a drug you take, the plan must inform you of this action in writing at least 60 days before removing it from the formulary. (Here’s an excellent reason for reading the mail your plan sends you!) This written notice gives you the opportunity to ask the plan to make an exception and continue coverage in your case, if your doctor confirms that the drug in question is necessary to your health.

This rule doesn’t apply when a drug is removed from the market for safety reasons — for example, if new research shows that its risks outweigh its benefits. In this case, you don’t receive a 60-day warning, and you can’t seek exceptions for coverage.

Making Sense of Special Restrictions on Some Covered Drugs

Perhaps you’ve found a plan that covers all of your medications. Great! What a relief, huh? But wait a minute. Does the plan require you to ask its permission before it will cover some of your meds? And if so, what’s that all about? Well, Medicare allows Part D plans to place restrictions on some of their formulary drugs in the interests of safety or holding down costs.

Here’s what these special Restrictions (which bureaucrats refer to as "utilization management tools") are called and what they mean:

F Prior authorization: You’re required to ask your plan for permission before it will consider covering a drug placed in this category. These medications are usually powerful ones that may pose safety concerns when used inappropriately or for too long. The plan authorizes coverage for such a drug only if it accepts your doctor’s statement that the drug is necessary to treat your medical condition.

F Quantity limits: This phrase Doesn’t Mean that your plan will cover your prescriptions for a certain time and then stop. It means that your doctor has prescribed a dosage or number of pills per month that’s higher than the plan considers normal to treat your condition. For example, if your doctor prescribes a pill to be taken twice a day (60 a month), and the normal quantity is once a day (30 a month), the plan won’t cover the prescription unless your doctor shows that the higher quantity is necessary to treat you effectively.

F Step therapy: Your plan requires you to try other similar but lower-cost drugs before it will consider covering the more expensive one your doctor has prescribed. This situation can happen if the prescribed drug has a generic or older version (or even one sold over the counter) that’s much cheaper. To avoid step therapy, your doctor must show that you’ve already tried lower-cost drugs that didn’t work as well for you as the prescribed drug.

As you can see, some of these restrictions address safety concerns. So you may suppose that all plans restrict the same drugs according to some general Medicare regulation. But no, the system doesn’t work that way. Instead, each plan gets to decide which of its formulary drugs requires prior authorization, quantity limits, or step therapy. This fact raises a question: Couldn’t a plan use these restrictions to discourage people with certain illnesses and who require expensive drugs from joining the plan? Medicare says no. Officials say the agency reviews each plan’s proposed restrictions every year before approving its application to provide Part D services so that plans can’t use restrictions to steer the sickest people away.

Getting the Drugs You Need When They’re Restricted or Not Covered

Earlier in this chapter, I explain the basic rules about formularies and special restrictions on covered drugs. These restrictions may never affect you. But if they do, what can you do to get the drugs you need? You can start by knowing how to avoid having to jump through these hoops to begin with. Already in a plan that restricts or doesn’t cover your drugs? Fortunately, other established rules give you the opportunity to get your plan to cover nonformulary drugs or to set aside its usual restrictions. I touch on all of these possibilities in the following sections.

Sidestepping the hoops

Although restrictions like prior authorization and step therapy may be of benefit in protecting people’s health or even saving them money, most Medicare beneficiaries regard them as a hassle — just more hoops to go through to get the drugs they need. But you may be able to sidestep these hoops by avoiding plans that restrict your drugs in the first place.

Each Part D plan chooses which restrictions it wants on which drugs, so these requirements vary a great deal. For example, the same drug may come with quantity limits under Plan W, step therapy under Plan X, both under Plan Y, and neither under Plan Z. This variation gives you a chance to find a plan that doesn’t restrict your particular drugs, or at least not all of them, in

Advance — when you’re choosing a plan.

You can find this critical information in any of the following ways:

F Compare Part D plans online at Www. medicare. gov, as I explain in Chapter 10. Each plan’s details show which of your drugs, if any, have restrictions.

F Go to the "Formulary Finder," also at Www. medicare. gov. Here you can find out which plans in your state cover all of your drugs on their formularies, and which cover only some of your drugs. Clicking any plan name shows whether it has restrictions on any of your prescription meds.

F Call the Medicare helpline at 800-633-4227. Ask the customer representative to find the plans that cover all of your drugs at the least cost and, among these, which have restrictions. TDD users should call 877-486-2048.

F Go directly to any plan’s Web site and look up your drugs on its formulary. Restricted drugs are designated PA (prior authorization),

QL (quantity limits), or ST (step therapy). You can also call the plan directly and ask a customer representative about drug restrictions, but be sure to keep a record of this conversation. If you enroll and then find you were given wrong information, you may be able to switch to another plan, as explained in Chapter 17.

Understanding the 30-day rule

If you’re Newly Enrolled in a Part D plan and are Already Taking any drug that isn’t on its formulary or has restrictions (such as prior authorization or step therapy), the plan must temporarily waive its rules and cover at least a 30-day supply of that drug. Medicare requires every plan to do so under a Transition Or First-fill policy To ensure that a patient’s treatment isn’t interrupted when first joining a plan. (People in nursing homes have the right to a 90-day transitional supply, as explained in Chapter 18.)

You can use this rule whether you’re joining a Part D plan for the first time or have just switched from one Part D plan to another. Just ask your pharmacist to fill your prescription on a transitional basis. Your pharmacist, or your plan, may contact your doctor to verify that you were already on this particular drug when you joined the plan. If your pharmacist denies you a 30-day fill, call your plan immediately. If the plan doesn’t help, complain to Medicare.

JttNG/ The 30-day rule is only a temporary respite, and you must take immediate

Steps to get the drugs you need when this period ends. Ask your doctor if the plan covers a similar drug that may suit you just as well (see the next section). Or contact your plan for an exception to its policy, as explained later in this chapter.

Trying another drug

^jfcDO©^ Perhaps you Can Use a similar drug — one that’s on the plan’s formulary and/ " or doesn’t come with restrictions — that may treat you just as effectively as

The medicine you’re taking now. The possibility is worth asking your doctor about. A similar drug, which may be an older or generic version of your prescribed drug, will likely cost you less, too. (I explain the meaning of generic and older meds, and how they can slash your expenses, in Chapter 16.)

Requesting an exception with your doctor’s help

By law, you have the right to ask your plan to cover a needed drug that isn’t on its formulary. You can also ask the plan to waive any restrictions it has

Placed on any of your drugs. This process is called Requesting an exception To the plan’s policy or, more formally, requesting a Coverage determination. In the following sections, I explain the process of filing paperwork for an exception request, what your doctor can do to help, how you can help your doctor help you, and what happens when your request is granted or denied.

The paperwork you need

In some circumstances you may not have to go through this process yourself. Sometimes pharmacists resolve the problem themselves — by calling your plan and maybe your doctor — without you ever knowing about it. And occasionally your doctor deals with the issue directly. (In fact, it’s essential that your doctor send your plan a statement saying why the drug in question is medically necessary for you, as I explain in the next section.) But in most cases, you need to apply personally, too.

To request an exception, pick up your favorite pen, fill out the appropriate form, and send it to your plan. You can obtain a form by downloading the right one from your plan’s Web site, or by calling the plan and asking that one be sent to you. Medicare also provides an acceptable template form that you can download from Www. cms. hhs. gov/MedPrescriptDrugApplGriev/ Downloads/ModelCoverageDeterminationRequestForm. pdf (so get those typing fingers ready!). This form, titled "Request for Medicare Prescription Drug Coverage Determination," asks you to fill out the following:

F Your name, address, Medicare ID number, and plan ID number

F The name of the prescription drug you’re requesting an exception for, the strength of the drug (for example, 100 mg), and the prescribed quantities (for example, 2 pills a day)

F Your physician’s name, address, and phone number, and his medical specialty (such as internist, family practitioner, cardiologist)

F What type of coverage determination you’re requesting — the form provides a list of possibilities, so check off which one applies to you

F Any other information you want the plan to consider

You can attach your doctor’s statement to the form, unless he prefers to send it to the plan independently. Then just sign the form and send it to your plan. If you need exceptions for more than one drug, you can make the request on separate forms and send them all in together.

What your doctor can do to help

To have any chance of succeeding in an exception request, you need your doctor’s help. In fact, without his supporting statement, the plan may not even consider your request — or at least, not in a timely manner.

Under Medicare rules, your plan must respond within 72 hours of receiving both your request And Your doctor’s supporting statement. (That’s 72 hours

By the clock, not business hours.) If your doctor thinks waiting this long would endanger your health or life, he can ask for an Expedited exception, A request that the plan must reply to within 24 hours (again, by the clock) or even less if your health depends on it. If the plan doesn’t respond within either time frame, you should immediately file an appeal, as explained in Chapter 19.

Table 4-1 shows you at a glance the different situations you may encounter, what you can do about them, and how your doctor can help.

Table 4-1 Teaming Up with Your Doc to Get Your Meds

A, or B

How you can help your doctor help you

A doctor’s help is critical to obtain a successful exception request. If you think this process is a hassle for you, consider what it’s like for your doctor, who may have many patients seeking help for the same reason and who doesn’t get paid for providing this assistance. Medicare prohibits doctors from charging patients fees for helping to file for exceptions.

^jjfcDOQfy Fortunately, most doctors — even if they grumble about the extra work Part D . /-ssstx Has imposed on them — put their patients’ needs first and are willing to do the paperwork involved in filing for an exception. However, you can score major Brownie points with any doc if you do your part to lessen the work he is doing on your behalf. Your health permitting, call your doctor’s receptionist and ask whether it would help for you to provide any of the following materials:

F A copy of your plan’s formulary: Your doctor needs to know which similar drugs are covered by your plan in order to explain why they won’t work for you. You can download the formulary from your plan’s Web site or call to have it faxed to you or your doctor. (Some doctors have these formularies in their offices, and some use computer programs that allow them to look up any Part D plan’s formulary instantly.)

F The phone and fax numbers of your plan’s Clinical Review Department: All

Exception requests must be sent to this department. You can call your plan’s customer service number to verify the appropriate contact information.

F A blank exception request form: Providing this form for your doctor may make the process a bit smoother. Ask your plan to fax a copy of its own form to your doctor, or visit Www. cms. hhs. gov/MLNProducts/ Downloads/Form_Exceptions_final. pdf to download the appropriate Medicare form. This form is useful because it asks doctors precise questions. However, under Medicare rules, no plan can insist that doctors use a form, but must accept any statement written on their letterhead.

F A set of instructions for doctors unfamiliar with the exception-request process: Obviously, a doctor who’s well versed in the process doesn’t need to see pointers. But if you’re the first patient your doc has helped file an exception for, you can find useful instructions from the Medicare Rights Center online at Www. medicarerights. org/PartD_for_ Physicians_national. pdf.

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It’s almost inconceivable that a doctor would refuse to help you request a Part D exception, especially if you’ve gone to the trouble of getting together the information in the preceding list. But it can happen. For this reason, Medicare proposed new regulations in 2008 (not yet finalized as this book goes to press) that allow not only physicians but also other health professionals who are qualified to write prescriptions — such as nurse practitioners and physician assistants — to file Part D exception requests. So if your doctor refuses to help you, ask whether anyone else in his office can. Otherwise, you can’t do much — except perhaps report the refusal to Medicare and take your healthcare elsewhere.

What happens when your exception request is granted or denied

In most cases, if you win an exception it’ll be valid until the end of the calendar year — especially if the plan grants you an exception to cover a drug not on its formulary or to waive quantity limits and step therapy restrictions. But when plans approve prior authorization for a certain drug, they can (and sometimes do) require another request after an interval of time (like one month, three months, or six months). In this case, you and your doctor must go through the exception-filing process again, and may even be required to do so repeatedly throughout the year.

What happens at the end of the year? If you stay in the same Part D plan, your exception may continue to be valid throughout the following year, so you wouldn’t need to request another. However, that depends on the plan’s policy. Some plans require new exception requests for the same drug every year. If you switch to a different plan next year, you’d certainly have to file a new exception request — unless you choose a plan that doesn’t impose a restriction on your particular drug(s).

If your plan denies your request for an exception, you can pursue the matter further by asking for a Reconsideration (asking the plan to reconsider its decision) and, if necessary, by taking the dispute to a higher level of appeal. You can also take these actions if your plan doesn’t respond to your request for an exception (or reconsideration) within the required time frames. I offer a detailed explanation of how to ask for a reconsideration or file an appeal in

Chapter 19.

Obtaining excluded drugs

If you need a type of drug that the law excludes from Part D coverage (as listed in the earlier section "The drugs that Medicare doesn’t pay for"), what can you do? The ban on barbiturates and benzodiazepines is especially controversial. These drugs can lead to oversedation (especially in nursing homes), serious side effects, and addiction. But they’re also commonly used to treat older and disabled people for conditions such as muscle spasms, seizures, sleeplessness, panic attacks, and other forms of anxiety.

If your doctor says you need an excluded drug, your options for getting it covered under Part D are limited. You can’t file an exception request for any of these drugs, unless your doctor has prescribed them for what Medicare considers a medically acceptable reason, as explained earlier in this chapter. Here are some alternative possibilities:

F Although hardly any Part D plans pay for brand-name benzodiazepines, a few plans cover generic versions of these drugs — for example diazepam (Valium) and alprazolam (Xanax). These are often enhanced-benefit plans that have higher-than-average premiums. So check plan costs carefully. Generic benzos aren’t expensive, and it may be cheaper to pay their full cost each month than to pay a higher premium.

F State Medicaid programs often cover prescription drugs that are

Excluded from Part D; so do many State Pharmacy Assistance Programs (SPAPs). If you’re enrolled in either of these programs, and your doctor says you need one of these drugs, contact the program to see whether it’s covered. (See Chapter 6 for more info about these plans.)

F If you have other drug coverage that wraps around Part D (like coverage from an employer), you may be able to use those benefits to cover these drugs, as explained in Chapter 6.

F You may be able to obtain these drugs from the manufacturers through their patient assistance programs, depending on whether you qualify according to the programs’ conditions and income limits. To find out, go to Www. pparx. org. (Check out Chapter 16 for the scoop on these programs.)

Getting drugs for off-label uses

Unless Medicare regulations change, Part D plans will continue to cover off-label prescriptions only if their usages are included in the specified medical compendia, as explained in this chapter’s "The off-label uses for some drugs" section. If the drug your doctor has prescribed as medically necessary doesn’t fall into this category, your chances of being able to appeal your plan’s coverage refusal are slim.

It may help to contact the Part D Appeals Project of the Medicare Rights Center, which helps Part D enrollees try to get the medications they need and has a special interest in off-label denials. Call the Center at 888-466-9050.

Also, your doctor may agree to argue the case with your Part D plan when requesting an exception by describing how an off-label use is the only means of alleviating your medical condition. She can do so by providing references to scientific research that demonstrates the drug’s effectiveness and has been published in authoritative medical journals. Success isn’t guaranteed, but the voice of a physician who can quote the relevant research carries weight.

Knowing When Drugs Are Covered by Part D, Part A, or Part B

As confusing as it sounds, some prescription drugs may be covered not only under Medicare Part D but also under Part A (hospital insurance) or Part B (outpatient care), both of which I touch on in Chapter 1. Sometimes an identical drug may be covered by all three but charged under one or the other, according to different circumstances. That’s because certain drugs were covered under Part A or Part B before Part D came into existence, and that. sjltBEA practice has continued.

Here’s the general rule of thumb on the differences:

F Part D covers outpatient drugs you administer to yourself at home, or that a caregiver administers to you at your home. (These drugs include self-injected insulin for diabetes, for example.)

F Part A covers drugs administered when you’re a patient in a hospital or skilled nursing facility.

F Part B covers drugs administered in a doctor’s office (such as injected chemotherapy drugs), hospital outpatient departments, and, in some circumstances, in a hospice or by a home healthcare professional.

These general rules are more complicated in some situations. For example, if your organ transplant is covered by Medicare, the immunosuppressant drugs you need afterward are covered by Part B. But if your transplant surgery Isn’t Covered by Medicare (perhaps because you received it before joining the program), the drugs are covered under Part D.

Part D doesn’t pay for drugs covered by Part A or B. So if any of your meds are in question, your Part D plan may require information from you and your doctor before covering them. Usually this info includes details of the related medical treatment (such as a transplant or cancer surgery). For this reason, plans often place a prior authorization restriction on such drugs, to determine whether they should be covered by Part A, B, or D. Your doctor may be able to settle this matter over the phone or may help you file a speedy exception request as explained earlier in this chapter. Either way, your doctor needs to explain why a prior authorization shouldn’t apply in this case.

Chapter 5