I’m a pharmacy technician. Elderly patients come into us lately and sometimes the prescriptions they normally pay $0 for have copays upwards of $100+. Naturally they’re angry want to know why they have to pay so much. Now I learned what the donut hole is in my training but honestly never fully grasped it. I’ll sometimes have to get my pharmacist explain it to patients and while he’s doing it I can see their eyes glaze over after about 10 seconds. Can an insurance expert or pharmacist explain like I’m 5 what it is so I can explain to our patients what it is like they’re 5?
In: 69
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
That seems a little fucked
Most Medicare Part D prescription plans have 4 stages.
Deductible: pay a large amount of the cost until you hit a threshold. This is usually a couple hundred dollars.
Standard coverage: normal copay structure until a certain dollar threshold of medication costs is reached, not what the patient has paid out of pocket.
Coverage Gap/Donut Hole: they will pay a larger percentage of the drug cost (not the pharmacy’s cash price, whatever’s been contractually agreed to between the insurance and the pharmacy), until they reach the final threshold.
Catastrophic coverage: they will pay a very small percentage of the drug cost for the remainder of the year. One year I had a customer literally pay like $1,500 for their Zenpep in the early part of the year and then they got a refill in at the end of the year and paid a little over $100 for the same amount.
This system has largely been in place since Medicare D became a thing in…2005 or 2006. Yeah, it happened under George W. Bush. Obamacare adjusted the numbers slightly, and I think made extra help a little easier to obtain. (Believe it or not, prior to this, if you didn’t have insurance through your employer’s pension program after you retired, you probably didn’t have prescription insurance.)
Jesus, nobody here has to pay for prescriptions. It used to be about £10 but that was discouraging people from taking necessary drugs. Don’t some people die from this??
Their eyes don’t glaze because they don’t understand.
Their eyes glaze because they know it’s bullshit and they’re getting fucked and it’s been like that their whole life.
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The donut hole will be eliminated in 2025 with the release of the Inflation Reduction Act (IRA) and Medicare Part D Redesign.
Thanks Biden.
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