Medicare Part D has been a blessing for many seniors that are on a fixed income and have a limited budget to spend on prescription medicine. However, for those patients that have a chronic condition, the Medicare Part D “donut hole” can be a real shock. At this time of year you hear a lot of talk about the donut hole or coverage gap. What is it, why is it there and how does it work?
The coverage gap (donut hole) was created to reduce the cost of Medicare’s Part D coverage. Each year, a yearly limit for Part D is determined. In 2007, the yearly limit was $2400. In 2008, the yearly limit was increased to $2510. In 2009 the limit is $2,700. The limit is calculated on the total costs of the drugs that you receive. This includes what the insurance company pays and your co-pays. For example, if a drug costs $550 and the insurance company pays $500 and the recipient pays $50, the amount that goes towards the yearly limit is the full $550.
While in the donut hole, you must pay for all of your prescription drugs out-of-pocket. There are several Medicare part D plans that offer coverage for generics when you are in the donut hole. This really isn’t that great of a benefit because these plans tend to cost more per month than most generics cost. For some people it might be worth it to have coverage for generics, everyone’s situation is different.
For Medicare patients with chronic health problems which often require expensive medication for treatment, the donut hole can be breached in a matter of months. In fact, at Rx HELP we have seen patients reach the donut hole as early as February. The reason for the donut hole was to encourage patients to use cheaper pharmaceutical products when possible. That is fine for those patients that have that option but it punishes those who must use expensive medications because nothing else works. For example, for patients with rheumatoid arthritis whose disease can only be successfully controlled by Enbrel, they can fall into the coverage gap within two or three months. Then, they must pay for their medications at full cost for several months until the catastrophic coverage portion of Part D kicks in, or suffer the potentially disabling consequences of stopping their medications. The cost of Enbrel is about $1,500 a month. There are a lot of seniors that are unable to pay for that.
Some patients will be able to qualify for patient assistance programs because of their income levels. For those patients that don’t meet the income guidelines for assistance programs, the only thing you can do is shop around. If you can afford to purchase your expensive medicine then Canada is where you will get the best value for your dollar.
The medication Enbrel as we mentioned is about $1,500 a month in the United States but in Canada it is about half of that. Enbrel is made by Amgen which is a U.S. based company in Thousand Oaks CA. Enbrel is manufactured at their plant in West Greenwich RI. From there it is shipped all over the world. It doesn’t matter where you buy it from; it was still manufactured in West Greenwich.
If you have a chronic condition that requires the use of expensive medication to control it, I urge you to contact us at Rx HELP. One of our patient advocates will assist you in determining the best and most affordable way to get the medicine that you need.