From A Letter Printed In Newsday:
…Newsday (Act Two, March 18) informed me that now lower monthly bills are just a tease, and the “doughnut hole” gap in coverage will be reached much sooner than I thought. Of course, I don’t know exactly how soon because I’ve yet to receive my promised monthly statement or even my payment coupons. When I call the insurance company now, a recording repeats that “the wait time is 40 minutes or more,” and if I need help, I should “visit the library or ask a friend!”
The “donut hole” is a gap in rx coverage; during that period, a beneficiary is completely responsible for his or her monthly rx costs, until a higher amount is reached. Then, Medicare D(isaster) will again a part of the tab for rx’s. One explanation:
The first is the calculation of the initial coverage limit. A beneficiary who reaches the initial coverage limit falls into the “doughnut hole” or coverage gap and becomes responsible for the total costs of all medications. The statutory standard initial coverage limit is $2250. This amount is reached by taking into consideration the full cost of the drugs, not just the beneficiary’s out-of-pocket cost-sharing. For example, if a drug costs $150 and the beneficiary’s co-payment is $40, the full $150 counts towards the initial coverage limit.
For the first $2,250, you and Medicare split the drug bill (Medicare pays 75%). After that, for the next $2,850 of drug costs, you, the patient, have to pick up the entire tab. Once $5,100 is reached ($2,250 + $2,850), Medicare kicks back in, paying 95%. People call this donut coverage; you get to eat a bite until you get to the middle, then you get nothing, but then you get donut again once (if) you get to the other side.
Another thing to realize is that the prices of rx’s have been escalating. The price of some oral cancer rx’s is about $4000 per month. So, using the figures above, a person will be eligible for one month of rx’s under Medicare D(isaster) and then has to pay out of pocket costs. In many instances, those most effected by this are those who are low-income and are unable to afford their rx’s.
As written earlier, Frances Blue, a retired teacher is fighting cancer. Prior to Medicare D(isaster) taking effect, her medications were affordable with some assistance from a charity rx program. According to the insurance carrier, she is now ineligible to participate in it, under Medicare D(isaster) regulations. Ms. Blue can no longer afford the cost of her rx’s. As she is now getting no medication at all, the cancer is spreading.
Her physician, Dr. Shore said he had expected Ms. Blue to be able to find a way to get Tarceva through Medicare. Ironically, he would advise her to pay the $2,800, but isuncertain that the drug will help, as he does not want to make her spend money for a drug that may not work.
Dr. Shore found Ms. Blue’s case situation and dealing w/all of the new regulations frustrating.
“We’re used to roadblocks. We’re not used to this.”
Despite all of the administration’s happy talk bout reaching other populations, this is going to get worse, as there are a lot more out there in similar situations.
