Doughnut Hole

I was reminded yesterday about the choices seniors often make when they enter the donut hole. For those who do not know about it, the doughnut hole is the part of Medicare Part D (the drug coverage part of Medicare) and it is the portion of the program that kicks in after a member pays $2,850.00 for medicine in a year. At this point the coverage drops considerably and the member pays a large portion of drugs purchased. This includes critical medicine like Insulin and others. Once the member is in the doughnut hole their cost for most medicine goes to about 50% of cost of the drug. After the member reaches $4,400.00 of total drug spending then the client reaches much higher level of coverage, where generics cost $2.55 per month and Brand name drugs go to $6.35 per month.

It is the general desire of the federal government to close the doughnut hole so this $1,550.00 has been shrinking over time and it is planned to shrink further as time goes on. The hardship occurs for those who are the most ill, have the most drug purchases, or experience the worst medical issues. It is a hardship that is well known in America and thankfully it is being dealt with over time. Hearing a person describe the issues they have when they reach this limit is disturbing. Having a person let you know they have not purchased insulin for two months because they reached the end of full coverage is one of the most difficult conversations I have ever had.

Just to be clear there are some rather complicated incentives designed to mitigate the effect of the doughnut hole. I have the program mitigation's many times this morning and I still cannot figure them out completely. I plan to get more educated about those incentives over the coming months. It is the least I can do if I hope to help seniors who may need our help.

The truth is that those of us who can afford insulin and the supplies because we have very good insurance are fortunate. This this past week I filled out my Section 125 reimbursement form, this is the annual federal government program that allows me to set aside $2,500 in income and shield it from federal and state taxes. My total for drugs alone last year was $2,980. In short had I been involved in Medicare Part D I would have entered the doughnut hole, albeit for a small amount of expenses. The difference is that I could afford the brief excursion; the person I spoke too yesterday could not.

All sounds like gibberish to those of us who are not involved. I will admit it is gibberish to me. I mean I knew of the “donut hole” I had just never been confronted with it. I think I am pretty up on issues involving the cost of health care in the US. But, I still cannot fully explain the doughnut hole. This is what I can explain, and it comes through pretty loud and clear. People cannot afford insulin. I suppose it hits me pretty hard since I have used insulin for 39 years and have always just taken it for granted. If I need it, I go get it. It has been pretty reliable method for staying alive. Even when I did not have insurance I had money to purchase insulin. Today, I have good insurance and little concern about what would happen if I could not get insulin.

I wish I could call on our community to band together and do something. Unfortunately I cannot. Yes I am insulin sensitive, but all other drugs are part of the doughnut hole. Anti-psychotics, blood pressure meds, test strips, and nerve issues that require medicine like Gabapentin. In short, it is easy to get on the high horse and parade around talking about insulin, but it is more than insulin, it is everything.

So what to do? Well for one the Affordable Care Act does lower the impact of the drought hole over time. By 2020 covered name brand and generic drugs will reduce to 25% of the cost of the enrolled drugs. This will reduce the cost of covered drugs considerably. But three things need to happen. First we need to keep pressure to hold Medicare advantages provided by the ACA. Repeal of these advantages might cause further significant issues for Medicare participants. Second, we need to help drug companies,(insulin makers, syringe makers and others) to enroll in or remain enrolled in the Medicare part D cost reduction program. Not all drugs will be covered, but we need to remember if some of us are not covered, we all suffer. No one is an island in the diabetic community least of all those with less income and likely more issues. Finally, we need to keep in mind that there are folks out there who cannot afford insulin. I am not saying we can do much, but making a choice of insulin or rent is devils bargain.

Yesterday I had my eyes opened about insulin purchases. I sincerely wish I had never heard of this issue. If you are upset after reading this, remember we are a family. It may be time to be vocal because a big part of the family is suffering and even more will suffer if this is not fixed. Let’s plan to do what we can to fix it.

Here is a PDF document that explains how the ACA closes the doughnut hole over time. It is great reading:



Views: 155

Tags: Doughnt, Hole, Medicare, Part-D, blog, diabetes

Comment by rick (aka: #blankieboy) on January 3, 2014 at 7:04am
Thank you lots. See I learned something else.
Comment by shoshana27 on January 3, 2014 at 8:00am

thank you rick & lots

Comment by Judith in Portland on January 4, 2014 at 12:35am

Great info. Thank you Dearhearts!!!.....


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