The Medicare Part D "Donut Hole"

I’m on Social Security disability and therefore also on Medicare. I’m not on Medicaid (or medi-cal, in CA). Medicaid is for people whose income is less than about $700 a month and they get all their meds covered indefinitely, but we’re still rather low on the income scale and I can’t afford my meds and Medicare “coverage” (Medicare Part D) is very limited.

Before the Medicare so-called “drug coverage plan,” I got all my meds free from the pharmaceutical companies since I did meet the low-income requirements. I had a grudging feeling of gratitude for this–realizing that the pharmaceutical companies do not do this out of a philanthropic spirit, but to ultimately boost sales by word of mouth or for some other self-serving purpose, like good PR.

Anyway, along comes Medicare drug coverage. I now pay $28 dollars co-pay per prescription. And my benzo’s aren’t covered at all. So–I suppose that still doesn’t sound so bad, but here’s the glitch–“THE DONUT HOLE.” A cute little euphemism for, “well, we’re just going to stop covering you all together for about $3,800 after we’ve spent about $2,500.” I’ve reached the “donut hole.” It doesn’t take much. It’s only June. In theory I need to spend $3,800 before I’m covered again. I freaked out, dished out $900 dollars last month and couldn’t deal with finding a solution at the time.

Yesterday I made some phone calls and let a few people in governmental positions get a piece of my mind. At this point I’m only on Lamictal and Risperdal and Klonopin. Like I said the Klonopin isn’t covered anyway and it only costs me about $22 dollars a month so I don’t sweat that. But the Lamictal and Risperdal are very expensive and since I’m tapering I have to get multiple different doses. Lamictal is a funny shape and does not lend itself to being sliced very well and I’m getting down to such a low dose of Risperdal that slicing large pills doesn’t work anymore either and I’m even needing to use liquid. So basically I’m getting three different doses of Lamictal and Risperdal both. (note–I do not taper both at the same time, but I am taking turns with them)

So that’s potentially approximately 6 prescriptions a month all of which are at least $200 dollars and often more. I usually don’t have to get all the prescriptions each month as I am tapering and by next month I won’t need one of the doses of Lamictal, but I’m still in pretty deep.

So I’m on the phone with my insurance company getting things straight–do I really need to spend $3,800? I really hadn’t understood that. Yes, that’s right I do. I give them a piece of my mind. I’m pissed. I apologize to the poor person on the phone who is gracious and says they understand. I tell them to pass on my complaints. I call Medicare–immediately go off and say how can you call this drug coverage?? I again apologize and say I know you are not at fault, but please pass my message on. She is very nice. She starts telling me to talk to my doctor and I can take generics, or over the counter drugs instead. I get irritated again and say, I’m sorry, but I’ve been a medical social worker, I know as much about drugs as my doctor–I don’t have options–I have to take these drugs. She finally gets around to telling me that some drugs are being covered during the donut hole period by the pharmaceutical companies.

I’d been told when the programs ended when I switched to the Medicare coverage, that the pharmaceutical companies would no longer cover me, so I got excited to find they’d changed their policy. She asked me what drugs I needed covered.

Lamictal is covered by Glaxo Smith Kline, Jansenn is not covering Risperdal. Well I felt great relief and that slimy gratitude again. I knew the reason Jansenn wasn’t covering Risperdal is because it’s going off patent soon. They have nothing to gain. I’m sure they want you taking Invega instead. (their new copycat patented version of Risperdal)

Anyway…because I was cutting down on Risperdal way back when I was getting it for free I have some reserve. I didn’t even have to buy certain doses of Risperdal last year at all. Just the smaller doses. Right now because of how my Risperdal is being prescribed–since it’s complicated with the tapering process, I actually have about 3 months worth of Risperdal. So since I’ll be getting my Lamictal free the picture is much rosier than it was before I made the calls. By next year hopefully I won’t get to the oh-so-cute “donut hole,” because I will be off most of my meds.

I have to add for those of you who don’t know. When the Medicare drug coverage bill went through congress a few years ago they were heavily lobbied by the pharmaceutical companies. With Republican support (I’m sure there were a fair share of Democrats involved too–they’re all in the pharmaceutical industry’s pockets) the pharmaceutical companies won out big. To explain, the Veterans Administration, for example is able to negotiate prices with the pharmaceutical companies and gets their meds cheaper. Well the pharmaceutical companies made sure that the government couldn’t negotiate cheaper drugs for Medicare recipients and hence, in order to be able to afford “covering” people they had to institute the donut whole.

This is all supposed to be revisited sometime this year I believe–perhaps there will be better coverage for the aged and disabled population covered by Medicare when it’s all over. I sure hope so since it’s truly potentially a tragedy for many people.