Donut Hole??

[CalfeeChick]

Not the kind you eat! Have many of you reached the Medicare Coverage Gap? My last prescriptions said I would reach it by June. This is the first time. I've been trying to find more info, but get confused when they start talking about percentages of this and that. It would be interesting to hear what you think, etc.

[Jesmcd2 CommunityAmbassador]

No clue CalfeeChick I got all excited about donuts! 🤤🙈

J🌠

[Midgey_Midge06]

Its very confusing. But while in the “donut hole” u can receive assistance for ur meds. Then wen u get to the other side of the donut hole u get “catastrophic coverage” which is pretty awesome cuz u pay hardly anything for ur meds then

[CalfeeChick CommunityAmbassador in reply to Midgey_Midge06]

Thank you. I’ve been trying to figure out on my Medicare & supplement insurance. Very confusing!

[Midgey_Midge06 in reply to CalfeeChick]

It really is. And at one time years ago i briefly sold medicare supplement plans. I still get confused. Everything changes every year

[itasara in reply to CalfeeChick]

I continure to be confused. I read the medicare book and I do speak native English, and after I read it I don't know what it said and that isn't because of a cognizant problem! So a couple weeks when I reordered my Copaxone, the pharmacist said yes I will meet the donut hole requirements and I think she said I get out of the donut hole soon; it never makes sense to me. After the first 3 months or so, after I have paid in almost $4000 out of pocket, I then pay about $875 for three months until the end of the last quarter, and then it is time to start all over again in the next year. Do I really get into catastrophic coverage? I asked her and she said that with the Brand name I'll always pays some portion of it. Not what I had read. So either I never get unto that catastrophic coverage or they are not transparent with me, or they may sure I never get out of the donut hole. I have an advantage medicare plan so maybe that makes a difference, but I'm not sure about that or anything when it comes to this insurance. My understanding is that once in the donut whole you end up paying more until you get out. I didn't believe that at first, but I read it in the medicare rule book. I have a friend who told me she makes sure she gets her medication in before she entered the donut hole because she would pay more. She may even skip doses to make sure she doesn't have to order it in the donut whole. She was right.

The pharmacy rep also said between my copay, and the pharmacy copay, the entire cost for Copaxone for 3 months is $20,000. I'm not sure who pays what, but I pay about ¼ or so of that myself in the first quarter. The retail price on my bill says $7000 which I think BC pays. i don't know who pays the rest unless BC makes deals with medicare.

SO SO SO CONFUSING, which is why I don't trust anyone anymore! When I reordered last Dec. the pharmacy automatically sent me the new generic medication equivalent of Copaxone. NO one asked me, my neurologist didn't call. It was about $80 less, but I was furious because no one contacted me. So my neurologist rewrote the Rx for brand name only. I returned the generic amount for a refund. When I reordered in Feb. the pharmacist told me it was better and less expensive for me to get the brand name b/c I was getting some kind of medicare discount. So if that is the case, why was the cost a little less when they sent the generic out? HOW AM I SUPPOSED TO TRUST ANYONE?

[CalfeeChick CommunityAmbassador in reply to itasara]

That is also what is confusing me. I'm not on the MS meds yet, but symptomatic drugs to just treat the symptoms. The are not cheap either. That is what is confusing me, I pay a co-pay, pharmacy says it saves me $xxxx dollars and when I look up my Medicare plus plan and my supplement, they say they paid at least 3 times the $XXXX amount, so what figures do I use for my calculations. I always get the generic when available, because even the co-pay on "Name" brands is too much.. Even my doctor appts are confusing in that the last time as an example, the detailed statement says it cost $300. for the nurse to take my vitals and the Dr's time was $600.. Then somehow, (I'm grateful!) the amounts are waived and I don't even get a bill. I know I will have a tough time in the "Donut Hole" and will never eat my favorite treat again. Thank-you for your info!

[itasara in reply to CalfeeChick]

It is all a mystery and from my point of view not very patient oriented. It is all big business.

[Rebelscooby]

I meet the donut hole in Feb. It is kind of great because I don't have to pay for my scrpts the rest of the year. Due to MS meds so expensive the one I was on was zinbryta

[CalfeeChick CommunityAmbassador in reply to Rebelscooby]

Are they going to change you to another med as the zinbryta was recalled? mymsaa.org/news/fda-helping... I guess I'll find out about the donut hole soon. Thank your Rebelscooby (are you from the Southern US? I have kids in SC )

[Rebelscooby in reply to CalfeeChick]

Yes they are going to put me back on copaxone 3 times a week I was on it everyday before. I am from the central US and I don't have any children. When you reach the donut hole we will happy when you go to pick up your meds and they say no charge.

[itasara in reply to Rebelscooby]

Now that I think of it although I still am not sure I understand that you end up paying more in the donut hole you don’t get a break until you get out of the donut hole. I still pay that co-pay of mine which is expensive and afterwards I pay a couple hundred plus dollars a month. I guess it’s a discount of sorts. And the insurance company say they are charged $20,000 a month or for the three months or something like that. I don’t believe any of them

[CalfeeChick CommunityAmbassador in reply to itasara]

It’s my Understanding that after you reach the catastrophic level of $5000, that the co-pays are greatly reduced but I can’t find any exact figures. It seems it depends on the medication. It is all confusing, and this is my first time in my life that I have ever been told I’m reaching the donut hole. So it’s a learning experience for all of us and for those that choose to share which I don’t mind we can share and learn from everyone.😊

[CalfeeChick CommunityAmbassador in reply to itasara]

I agree with the ins saying they are paying oodles of money a month. None of seems to jive together, but not much we can do. Maybe get political.. I think we are paying for their maintenance, salaries, research of new meds, etc. and what they have to pay out to stay on top in the health & medicine fields.

[Momjules]

I’ve been out of the donut hole over a month now.

Ms meds and mris will do that

[CalfeeChick CommunityAmbassador in reply to Momjules]

Will your meds/mri's be less for the rest of the year?

[itasara in reply to CalfeeChick]

I don’t think treatments or diagnostic tools like MRI have anything to do with the donut hole which is pharmacological. I’m not sure . I finally had an MRI done and I have not been billed but I think according to the Medicare book it should cost me something like $50 or maybe more I’m not sure. I’m sure I’ll find out soon.

[itasara in reply to itasara]

Actually my MRI cost $131 and the bill for the doc to read it was $22. Just got the bill.

[itasara in reply to Momjules]

as I said, I'm not sure I ever really get out of it. or if I do, I still pay ...

[itasara in reply to itasara]

I spoke with pharmacy today. I am out of the donut hole so I pay something like $225 a month for my Copaxone rest of year.

[Momjules]

Yes my pain pills. Hydromorphone is now 1.10 for 40 pills.

My diabetic pens in a box of 5 costs 18.00 dollars

Generic plavix is about 4and change

I’m not too afraid to pick up meds.

One box of lidocaine patches which have 30 are about 7-9 dollars.

[kris1973]

Here is a chart that may be helpful: google.com/search?q=2018+me...

It changes again in 2019. -Kris

[CalfeeChick CommunityAmbassador]

Just for clarification, I reach my "Donut Hole" when Medicare and my supplement say they have paid $3750. out of their pockets for my prescription meds only. Then I pay 100% until it reaches $5000. Then I would go on what they call "Catastrophic" coverage. I don't know if that varies per person. It would seem if you are on Medicare and a supplement, those figures should apply to all. Yes, Jesmcd2 I get excited about donuts too!

[itasara in reply to CalfeeChick]

I pay what you do to get into the hole but not 100% in the hole. I think I pay 58% in the hole until I reach $5000 or more? It’s in a booklet which I don’t have in front of me now. I’ll try to get back here with exact info.