[Madelaine Amee]

I am posting for discussion, not for any other reason.

I have a heart condition which necessitates me taking three meds a day. Yesterday I went to pick up one of the meds and was told I was in the MediGap and my cost had gone from $114 to $381. Not only for that particular medication, but all the other meds will cost more because I am in the MediGap. This continues to the end of the year and will end up costing me well over $1,000. I have the best Plan you can buy for both health and RX and I still got caught in this donut hole.

The flip side of this is if I don't take the meds and had the heart attack or devastating stroke my insurance would cover EVERYTHING and keep me alive which would be an astronomical amount of money.

I am fortunate, I can afford to buy the meds, but what about the people who really cannot, what do they do and how much stress do they live with day in and day out.

[dillywho]

Originally Posted by Madelaine Amee

I am posting for discussion, not for any other reason.

I have a heart condition which necessitates me taking three meds a day. Yesterday I went to pick up one of the meds and was told I was in the MediGap and my cost had gone from $114 to $381. Not only for that particular medication, but all the other meds will cost more because I am in the MediGap. This continues to the end of the year and will end up costing me well over $1,000. I have the best Plan you can buy for both health and RX and I still got caught in this donut hole.

The flip side of this is if I don't take the meds and had the heart attack or devastating stroke my insurance would cover EVERYTHING and keep me alive which would be an astronomical amount of money.

I am fortunate, I can afford to buy the meds, but what about the people who really cannot, what do they do and how much stress do they live with day in and day out.

I have the same issue with my husband...it takes him about 30 minutes to get to the doughnut hole (exaggerated a bit, but close). I guess those who cannot afford the meds get a break. Notice the ads that say, "If you cannot afford xxx, "manufacturer" may be able to help. You could get xxx for as little as $15 (or some whatever)"? My question is: If they can do it for some at $15, why not all? Personally, I think it has to do with all the monies they spend on advertising throughout all avenues....TV, 3-page color magazine ads, radio, etc. "Ask your doctor if xxx might be right for you". Like I told mine, "If you don't know what's right for me, then I need to find another doctor." I can also obtain meds through a Canadian Pharmacy, which I do in addition to the insurance system. PM me and I will give you details, if you are interested. One of his most expensive ones, I get that way and it actually comes from a pharmacy in the U.S. Go figure. Instead of the $131 with insurance, and three times that in the infamous "hole", it is $111 from them.

Ridiculous, no?

[blueash]

The donut hole is complicated, and the rules change every year to the benefit of the consumer.
For 2018 you have a maximum out of pocket cost of $5000 for drugs. After you spend $5000 all your covered meds are paid nearly 100% by insurance. There is partial insurance coverage for formulary meds for the first $3,750 in drug cost [cost is the total spent by you in copays and the insurance company in their coverage]


After 3750 the coverage changes to the donut hole Before 2011 you paid everything until you reached that out of pocket max. In 2018 you paid a highly discounted cost of the medication

While in the coverage gap, you’ll typically pay 35% of the plan’s cost for brand-name drugs and 44% of the plan’s cost for generic drugs in 2018.

So even in the hole you are getting a substantial discount on the cost. The donut hole is scheduled to disappear in 2020. This elimination is one of the features in the ACA also known as Obamacare.