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?
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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.)
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