Monday, November 16, 2009

The Donut Hole

Well, it happened. I hit the "donut hole". It really surprised me, since I had just received a statement from my Rx insurance company, telling me I had quite a bit more money to spend on prescriptions before I got to that donut hole. I went to the drugstore to pick up my nitro Rx, which normally costs me a co-pay of $24. When I asked for it, they told me it would cost $153.34 this time. Well, I didn't have that much money with me of course, so could not pick it up.

Went home and called the insurance company. "Oh yes. You've hit the donut hole." When I checked their statement, it had been dated Oct.26. Since that date, I had picked up a couple of more prescriptions. Of course, I had never been given a list of what my prescriptions actually cost the insurance company either, so had no way of judging when I got close to the infamous donut hole. In fact, I went back and read the statement, and it said very clearly that the amount I was supposed to be going by was the out-of-pocket money I spent. Silly me. I believed what I had read.

So I asked the woman on the other end of the line if that meant that for the remainder of the year I would have to pay full price for all of my prescriptions (while continuing to pay the monthly premium). She assured me that yes, that's what it means. Well, by my figures, that means I will have to come up with another $413.48. And Christmas is coming. And I live on Social Security, basically.

I still have a terrible time wrapping my mind around the fact that the insurance companies are permitted to charge whatever they will, plus some pretty high co-pays, varying widely depending on the medication, then simply stop covering anything after you've reached a certain amount. What is really laughable is that they assure you that the period in which they do not cover anything is "only until" you've then reached another amount, when they will start reimbursing you in part for the rest of the year. How can people who have next to nothing to begin with reach that amount at all? We can't afford to buy most of our meds, so we will never reach the next mysterious level. I would so much rather pay more each month, and remain covered for the year.

I have only been covered by this insurance since April. Had I started at the normal time - January 1st - I would have hit the donut hole by April! For that matter, it would have been sooner if they had been permitting me to use the diabetes medication my doctor prescribed. They denied that, and I have been fortunate enough to have doctors who have given me samples of it all this time, since June. (The generic form is NOT the same.)

Well, as of January 1, 2010, I will be using Aetna instead of this company. I am quite sure it will be better. Just a little better financially. Much, much better in that they seem to be far more efficient and definitely more informative and willing to answer questions. I will still reach the donut hole long before the year is up. How I will handle that, I have no idea.

Medicare Rx is the worst thing that has happened to seniors in many years. The AARP pushed hard for it. Sure they did. They are not much more than one big insurance company themselves. I know - they are supposed to be non-profit and only looking out for our interest. Tell me another fairy story! However - AARP is now endorsing H.R. 3961 and H.R. 3962. Passage of these bills would mean closing the donut hole and lowering prescription costs. Why are they now in favor of the change? I don't know. Maybe they have seen what it is doing to us and have realized their mistake. Whatever their reasoning, I am grateful for it. My own Republican representative is against these bills. Mr. LoBiondo claims government interference will be disastrous. Well, Mr. LoBiondo, isn't it the government backing your own super terrific medical coverage? If you were facing what we are facing I am sure you would be a lot more agreeable to passage of these bills. They are far from perfect, but they are certainly better than this. At least they head us in the right direction.

Good lord! How trite that sounds! I can't think straight this morning.
Please forgive the scattered thinking and really bad writing in this post. I guess I'm still too upset by the whole problem to collect my thoughts.

In answer to a couple of comments, I do use Walgreen's Pharmacy, and think they are great. But the pharmacy does not set the co-pay - the insurance company does. And even for those with low co-pay arrangements, that does not alter the rate at which the donut hole is reached.


Anonymous said...

Oh my! This is not good. We all need our prescription coverage for our medication. I hope everything works out quickly.


Christine Gram said...

I don't know if this can help, but when we moved overseas, we stocked up on a years worth of prescription drugs... we had the scripts from the doctor for them, but insursance wouldn't cover it all at once, so we had to buy them ourselves. We use Long Drugs. Turns out, that Longs charges people who have to pay for the drugs much less... in some cases, the meds were less expensive than the co-pay I was paying ($10 co-pay, but if I just bought the drug without insurance it was only $4). Long story short, maybe ask at the pharmacy about this.

Sylvia K said...

Bobbie, I do so understand where you are coming from and you have reason to be upset. So far my drug coverage is holding up, but I think I've told you what I have. Fortunately, only two of my prescriptions are pricey even with the co-pay and the others are $10 or less for 90 days worth. I have gotten some good prices at Walgreens, it might be worth asking the pharmacy.


Daryl said...

Some of the insurance company dictated prices are not co-pays per se but percentage pays .. I know because I had a conference call with Aetna and Wageworks (who handles the Flex Spending account I have through my office)... nevertheless its insane. I too have hit the donut hole (tho I never heard this term before now) but I am paying out of pocket for the 5 meds I take between end of October and end of December... SIGH

Dianne said...

I have one med that Lilly is giving me for free for one year - don't what I'll do after that

I have just stopped taking 2 others and have found herbal equivalents - I hope I know what I'm doing

The one Dr I'm still seeing since she charges me whatever I can pay since I lost my insurance is giving me samples whenever she can

I think AARP is now behind the bills because they have been SO watered down that they may actually give us something WORSE than what we have now

Healthcare Now and Dennis Kuccinich have both been sending info warning us that these bills - and the Dems - do not reform healthcare

I'm so sorry you're going through this Bobbie, you know that I know exactly how you feel

Crayons said...

This is terrible news. I'm very sorry for what you are going through. I have often purchased medication from Canada. It's not always very much cheaper, but sometimes it is. Just Google your med + Canada.

But thanks for the good analysis of AARP. I've never really understood what they stand for or how they operate.

Dawn Fine said...

I am so sorry Bobbie..We really need something better for people like you ..I hope legistlation is passed to close that donut hole...and make things easier for you and others in your situation.

kenju said...

Mr. kenju hit the donut hole in July this year, Bobbie. We just found out that our current Medicare advantage plan is going to charge more in 2010, the amount at which we will hit the donut hole is smaller and our co-pays are going up. We are getting screwed from every angle, and yet it is the best deal out there for us. Our provider is trying to get everyone to go to a PPO plan, but so many docs and hosps. don't accept that. We are truly between a rock and a hard place. I hope the proposed plan passes!!

Rambling Woods said...

Darn insurance companies and that is why I am so angry at AARP and why we need reform....

Lisa (Mountain Photog) said...

I'm so sorry to hear about the terrible situation you're in, Bobbie! Something has to be done. . . Are there any programs in your area that might help you bridge the gap?