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.
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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.

Thank You, Walgreen's

In the past several months I was forced to look for a new prescription coverage insurance company. I had coverage for my medications from my former employer who suddenly gave up offering such insurance for its employees and ex-employees. I was now faced with the task of finding someone new who would cover all my medications under the Medicare system. I first called the insurance agent who had helped me a few years earlier to find someone to give me secondary coverage for Medicare. He had been very helpful at that time. This time he let me down. I guess there was no profit in it for him, and he seemed disinterested. He did half-heartedly supply a company name for me.

I then went on line myself, checking out the name he had given me, and others. The number of companies out there was mind-boggling. Their web sites were very confusing to me. I have used computers for several years now, but for mostly recreational purposes. Even while I was still working, my computer use was restricted pretty much to certain programs used by our department. I am far from computer literate in other areas. I can't help but think of the thousands of people my age who have had no experience at all on a computer. As we grow older, our minds are not as sharp as they once were, despite our attempts to keep them active. And for many of us physical problems add to this.

The insurance company I chose has turned out to be completely unsatisfactory, and pretty darned expensive. Having no previous experience with such coverage, I really didn't know what questions to ask, and they didn't give me much detailed information up front. I've learned the hard way. So at this point I need to find another company, and prepare to make the change in November, when such a change is permitted.

I am fortunate in that we have a Walgreen's Pharmacy nearby now. That is where I turned for help this time. They took a list of all my current medications and supplied me with a print-out of all the companies available to me - ALL 64 OF THEM - and listed the first five they consider as offering the best plans for me. They gave me the estimated costs and showed me which medications on my list were covered, as well as other pertinent information.

I can't tell you how much this is helping me! For other seniors out there, I strongly recommend visiting Walgreen's, or some other pharmacy if you can find one offering this kind of help. It is a daunting task without their help. When the Medicare Rx plan was proposed, I wanted no part of it, and was disgusted with AARP's backing of it. They got it through, and now we're stuck with it. 64 different companies? Gee, thanks. And every one of them (including AARP of course) out to profit from it to the max. They tell us that AARP is non-profit. I'm afraid I would take some convincing on that one. They seem to me to work against the people they claim to be working for. I suppose I could be wrong - God knows, that's happened before - but I certainly don't champion some of their causes. And any time I have had occasion to telephone them, I find them extremely unhelpful, whatever my question or problem.

At any rate, come November I hope to find myself happier with my insurance and just a little better off financially. Ya gotta have hope.
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What makes the choice so difficult is that there is no such thing as the perfect plan for all. What would be ideal for one, is disaster for another, based on which particular medications the individual must take. Some medications cost at least a couple of hundred dollars a month, and so co-pays are astronomical, and vary company to company.

I do appreciate some of the comments I have received, but if I can't figure it out in my own case, how could I hope to make sense of it for other people? Common sense is one thing. Sorting through economics and life situations for a stranger is something else entirely.