Medicare Part D and the Donut Hole: Stories
Part D "Donut Hole" Stories
Too many seniors live in fear of the "Donut Hole." Here are some of their stories:
Carolyn from Polk, Iowa:
Carolyn and her husband enrolled in Medicare Part D in March. Carolyn's husband is very ill, and they anticipated hitting the donut hole. As of the end of April, Carolyn had said that they had racked up 1702.89 towards the donut hole, and believes they will be getting to the hole soon. Carolyn has indicated that she believes that the amount that they have been putting toward the donut hole is too high. She said that last year one of their drugs was $50, but now it is listed as $141. She has said that her husband relies on free samples that the doctors give them to stretch their budget and put off when they will reach the donut hole. She is computer savvy, and had a hard time finding information to make the best choice, so she wonders how seniors without those skills could handle the process of enrolling.
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Elizabeth from Polk, Iowa:
Elizabeth had a lot of difficulties with the sign up process. She found that signing up was very confusing for her. Elizabeth went to a town hall meeting as well as educational seminars on Part D, but after all of that, she still felt that she was having problems understanding everything. She signed up at the last minute to avoid being penalized, however she was not sure that she made the right decision. Elizabeth was denied drug coverage for a certain Cancer drug she was prescribed and told that Part D doesn't cover it.
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Phyllis from Polk, Iowa:
Phyllis's husband is on dialysis machine in their home. He was being helped by programs that companies offered to lower his costs, however they were discontinued on May 15. He was left with no choice but to sign up for the benefit. They have found that navigating and filtering through the 41 plans to be very confusing for them. In addition, Phyllis' husband has not received his cards from his insurance company yet.
Ruth from Kanawha, West Virgina:
My husband and I live on social security.We had planned our retirment but when my health insurance was canceled and I had major health problems it took all our assets.I am recovering from breast cancer have diabetes, chronic hypertension,arthritis and thyroid disease also enlarged heart. My husband has CHF arterial fillibration,diabetes,arthritis, and emphzemis. If we paid out of pocket for meds we would have ninty five dollars left to live on. We have been on a program with WV Healthright that enables us to get meds.I was told that tamoxifin which I need to take till next Feb will no longer be availible and it is too expensive for us to buy. We called medicare because my husband is on medicare and I will be in August. We were told it would cost 4000 a year each plus the reg medicare premiums No way we can aford it. NOW they are saying soon we can't get meds from Healthright if you are on medicare.We could go without eating and still not have enough for the medicines. People will be dying because of this program. You either need to have other insurance, be solvent financially or be in extreme poverty for this program to help. We worked hard all our lives , lost all or money because health issues and now it seems soon we will be unable to get our meds.None of our meds are for pain or nerves all life sustaining.I am so tired of being told Mam you make fifty dollars too much to qualify for this program or that one.Other countries provide for the sick and the elderly. We worked all those years didn't ask anybody for anything ,paid our taxes and only to end up in a delimma of getting meds or living expenses. We are more blessed than many and can speak out.Therefore let my voice be for the ones to sick or not educated enough to speak for themselves not just us. Come on America do the right thing.
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Doreen from Maricopa, Arizona:
About three years ago, at the suggestion of our internist, we began purchasing our medicines from a reputable pharmacy in Canada. My wife saved about $100 per year on her Climara and Miacalcin and I saved about $1000 per year on my Lipitor, Tricor, Benicar, Proscar and hydrochlorthiazide.
On June 15, 2006, my wifeÂ's three month supply of Climara from Canada was siezed, without warning or prior notice, by US Customs and Border Protection. We receive our prescription drugs from Canada. One of the two drugs I have taken for years was interdicted at the border by the U.S. Customs and Border Protection without warning. A form letter arrived on June 15, 2006 telling me that my drug, Climara, made in Canada would be destroyed within thirty days because it is an unsafe drug. Climara is FDA approved. To imply that this drug is unsafe slanders the Berlex Canada company and implies that my gynecologist prescribes unsafe medication for her patients. The cost of Climara is triple the amount if purchased in the U.S than Canada. The cost of Miacalcin distributed by Novartis is approximately triple the cost if purchased in the U.S.
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Edith from Connecticut:
I am 77 years old, but I have always been healthy. I recently had surgery for my eyes-to improve their condition-but I have never had an operation before. Except for when I had my children, I've never spent any significant time in the hospital. And except for the recent eye drops I was on briefly, I'm not on prescription drugs. That's why I didn't sign up for the Medicare Part D plan. However, I am worried that even though I don't need prescription coverage now, I am jeopardizing my benefits for the future. I am worried that I am going to be faced with harsh penalties that I can't afford.
My husband did sign up for the Part D plan, but I am worried about that too. He was diagnosed with Parkinson's three years ago, so he does need prescription drugs. However, signing him up for a plan was very difficult because we are not computer oriented and our children don't live very close. It was a really confusing process. He ended up with Cigna, but we aren't sure if it is the right plan-he might end up paying for his drugs out of pocket and they cost about $200.
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Gerry Guerra from New Jersey:
My husband & I are each enrolled in different plans. I currently only take one prescription drug, however he takes several. One of the problems he has encountered is the company denied Lipitor even though it is in their formulary (they have continued to fill his prescriptions for it though). We did appeal the decision and they said that his doctor said he wasn't the prescribing doctor, when, in fact, they spoke to an associate of his doctor. The next problem he encountered is in needing a pre-authorization from the drug company for a certain drug. I feel strongly that if our doctor prescribes a particular medication, he is aware of the cost and has a sound medical reason for prescribing it. The decision should not be made by a company who has never met us and certainly does not have the medical history or the background to judge which drug is right. I realize the cost factor is of concern, however I feel the prices of the drugs is ridiculous and we have no control over it or our well being. I just read an article in which NJ Citizen's Action made a very sensible recommendation: That Medicare Part D should be run by Medicare and they should bargain with the drug companies the way the VA does. I couldn't agree more. No wonder so many people are moving out of NJ, it is becoming impossible to live here.
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Jacqueline DiConstanza from Lodi, New Jersey:
I had a drug plan with Horizan. I rushed to join part D because I did not want to pay two deductibles. No one explained to me that the cap set on part D included what I paid, the deductible plus the co-pay. The end of the year is going to be a nightmare for me. I am sixty eight not able to work any longer. My husband is seventy and has to work to pay our medical expenses, mostly medications. There are no generic drugs for my prescriptions. If my husband can no longer work we will have to sell our home that we bought and struggled for since 1959. The question here is where is cheaper?
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Janis Stone from Maine:
I don't know about others, but we have already met the $2250.00 and have had to pay the next out of our pocket. We met the donut hole by July. We are not a wealthy family by any means and this is a big drain on my money that I earn. At least I am working, but I need an operation and am going to be out for maybe 2 months with no earnings with that big bill to pay. It is on our credit card which is usually paid in full each month, but this next time will not be paid at one time. I thought things were going to be better, but I guess I was wrong.
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Lydia Richards from Maine:
My husband and I are both on disability for our mental health issues. I have been able to work part-time for the last 7 years. Together we take 10 different medications not including PRNs that I have for asthma. Before Medicare Part D, we both received the majority of our meds through the Pharmaceutical Companies indigent programs. I paid for the 2 meds that were affordable. Now we not only pay for the premiums but the medications are costing us a lot-co-pays are $5, $26, $52. It is now costing us over $300 a month just for meds. Before Medicare Part D it was costing $10. Thanks for helping!
Anne St. Pierre from Lewiston, Maine:
Anne St. Pierre is currently caught in the Part D doughnut hole. She pays a $27 premium per month. When she goes to the pharmacy to get her prescriptions each month the bill comes to $171. The insurance only covers $8 of that bill. Anne is left paying $163 per month for medication she needs to survive. "When I have to pay $27 a month to the insurance to get a cash return of $8 it is absurd. I have to dish out $163 for my pills per month and they only pay the $8" says Anne St. Pierre of Lewiston who used to get free prescription drugs before the Part D program came into effect. "I'm in the doughnut hole and I don't know how I am going to get out." Anne and her husband have trouble every month making ends meet - at times they are faced with tough choices - do they pay for groceries, pay for heat or pay for their prescriptions.
Lou Bennett from Maine:
from article: "For her 77th birthday a week ago, Lou Bennett asked her children for help with prescription costs even though she has a drug benefit through Medicare. Coverage had stopped because just six months into the plan, she had used $2,250 in drugs - paid for with $750 of her own money and $1,500 from insurance. Coverage will not resume until she spends another $2,850 on her own, bringing her out-of-pocket cost to $3,600. Bennett, of South Portland, always knew she would hit the limit - just not this soon. "I think I was somehow in denial about how much this would impact my finances," she said." (interviewed by Josie Huang for 7/25/06 Portland Press Herald article)
Tina Gilbert from Auburn, Maine:
My name is Tina Gilbert and I am 63 years old. I grew up in Auburn Maine where I still live today. I am on Medicare and spent the last 8 months trying to sign up for Medicare Part D. I live with a disability - a brain injury caused by a hit and run car accident. After the car accident, I had no means to continue paying for health insurance at a time when I needed it most and due to the injury, I can't work full time. I went through an eight-year process of trying to find health insurance - first I was just paying for health insurance out of my pocket. When I realized that it was health insurance or food, I went two years without any insurance at all. I wasn't able to get the rehabilitation I needed for my brain injury because I didn't have insurance - the rehabilitation could have helped me to recover fully. Finally, five years ago I began receiving Medicare. First, I was on Medicare but paid $200 a month for my medications out of pocket. I was finally approved for buy-in Medicaid that helped pay for her medications. When I heard about Medicare Part D I began the application process in January of 2006. It has taken me from January until now to figure it all out and I still don't understand it. The people who were helping me sign up didn't understand all the different parts of Part D and gave me mixed messages all the time. They didn't know the best program for people. Elderly people are so messed up over it. This is a life-threatening situation for thousands of Mainers. Part D is so confusing that I don't understand what I am getting and why I am getting it. People who receive insurance should understand their coverage and not be fearful that one day they'll get a bill and have to choose between medication and food. One day we get insurance, the next day it's taken away, and the following day we have to sign up for all these different programs. The Medicare Part D confusion needs to change.
Mike Reynolds from Lewiston, Maine:
Journalists are supposed to be objective, yet it is impossible for me to have any objectivity over the new prescription drug plan offered as part of the new Medicaid part D coverage. As an individual with a disability, I knew this was going to be a bit of an adjustment. The difficulty I experienced, however was totally unpredictable. I feel I did have some benefits; my best friend is a technician at the pharmacy where I get my medications. I have worked in the insurance industry, and I would like to think I advocate for myself effectively. All of these assumptions would be tried in my mind in the month of dealing with part D.
I should preface this with the fact that I did go through a medicine change that was unexpected and unrelated to Medicaid. I am disabled due to Cerebral Palsy (CP) and also have a diagnosis of Panic Disorder. The CP is due to a difficult birth, my Panic Disorder was diagnosed when I was 15, though I know I have had it from a very young age, I think my first panic attack was at 7, which wasn't considered plausible when I was growing up. I need various durable medical items to get through the day, but since this law did not affect DME, there is no need to really discuss the entirety of those needs.
I tried to get a drug I was out of on December 30th. However, there were some complex issues with my doctor's office, the drug was never refilled, and I found myself without it for a week. This drug was a form of neurontin, which I was taking for post surgical pain and spasms, which had been treated with physical therapy. I had some of my Lexapro, which I had used for years to help with my anxiety issues, in conjunction with a script for klonoprin, a drug I have been on since I was 17.
On January 3, I went to go get my klonoprin refilled. I had my part D card from a company, which, I guess was better than some folks, who did not even receive any information in the mail. I also have since learned that this was the program the government threw me into, without looking at my medicines at all. My friend informed me that no drugs in the same class as my klonoprin were covered by any plan. My neurontin drug was to be picked up at my doctor's office as it was also, not covered without some lengthy paper trail. This had already taken a couple of hours, and as I was going home, my friend called my cell phone and let me know that my Medicaid was also somehow cut off. This was more than 2.5 hours after "just trying to get a script refilled." It took an hour to go to the Human Services office and get my Medicaid re-instated. It was discontinued due to a computer error. I received a letter and was told by the pharmacy I could get my drug refilled in 3 days; luckily, I had enough to last those 3 days. I went home exhausted, physically, spiritually and mentally. I am usually a resilient person, but this had left me wiped out. I was left wondering why part D didn't pay for meds I needed to stay sane. Was I some sort of horrible person for needing the medication? Was it a frivolous drug expense? I went to sleep early, my partner looking in on me, as I seemed a bit distressed.
The same week my body went into crash mode, or just basically deciding it would not cooperate with what a 32-year-old body should do. I had lost bowel control, something that has happened before but after the third day of "oops," my partner decided that maybe an ER visit would be advisable. I had no idea why my lower half of my body just stopped and said to my brain "He, you thought you had control of us, eh, well, we're rebelling, and you can't stop us."
The ER visit sucked, most do, but this even more so. Instead of my neurological impairment being the main focus, my sexual preference was somehow more important. The ER attending ruled it a bout of diarrhea, a dubious diagnosis because I know my body, it wasn't that, but after four hours in the ER, I could care less, I just wanted to go home.
I decided to see my general doctor. He was on vacation, but I got a script and the need to try and get on a bowel program seemed to iron things out. My doctor came back and decided to change my anxiety meds to see if a different combo worked. It did, but a bit too well; I was constantly tired and stopped after a couple weeks.
My disability does have some effects on my body that are less than desirable, but after the runaround I have dealt with part D of Medicare, I cannot see how this drug benefit really helps anyone except insurance and drug companies. I mean I am glad I have coverage, and I am glad Maine is one of the states that made sure that there were some stopgap protections. Certainly I cant be the only one with these problems, but after the amount of bureaucracy, I can only imagine how other people who may not have the education or background, or a good friend who knows the benefits from working in a pharmacy and was helpful enough to tell me that my Medicaid was cut off, which probably saved me time by getting it all done in one day. So I guess I'm frustrated, but overall, not hurt by Medicare part D. I just hope they don't plan on doing this to DME supplies or it will be an enormous headache.
Avis Poole from Maine:
from article (edited): "Poole, an 87-year-old widow... takes six medications for the heart condition, cholesterol and arthritis. She joined [Medicare Part D] rather than continue with her late husband's insurance because it looked like a better deal. But her costs for two drugs - Coreg and Lipitor - jumped Aug. 2 nearly $50 a month. ''It's quite a chunk out of my monthly Social Security...'' Recipients like Poole start off with a $250 deductible and a monthly premium of around $35. Once the $250 deductible is reached, Medicare pays 75 percent of prescriptions up to $2,25. At that point, recipients get zero coverage until they've reached $5,100 in total spending, hence the so-called ''doughnut hole.'' After reaching the $5,100 threshold, the government resumes paying 95 percent of all drug costs for what is called catastrophic coverage. Beneficiaries would still owe a $2 co-payment for generic drugs and $5 for brand-name medications. But for Medicare beneficiaries like Poole, getting caught in the coverage gap could cost her nearly $500 per month - money she says she doesn't have on a fixed income." (referred by MPA and interviewed for Bart Jansen 8/28/06 Portland Press Herald article)
David Storer from Portland, Maine:
David is on disability due to a lung ailment. "Because I take so many drugs, I've already hit that plateau where a person has to pay out the thousands of dollars in between. There's just no way to do it. So my doctor is trying to find a way for me to continue taking my medication without my having to pay out more than I make in a month for my drugs."(referred by MPA and interviewed for 9/18/06 Maine Things Considered public radio piece on "Doughnut Hole Day" rally outside of CVS pharmacy in Portland)
Patricia and Vern from Plymouth, Maine:
Vern has stage 4 lung cancer and turned 65 in April. He signed up for Medicare Part D at that time. There are a few medications that he has to take that keep him going; he has already gone through chemo to the point where he is immune to the treatment. After a month of purchasing the necessary drugs, he hit the donut hole and had to pay $2,800 out of pocket. Not only did they hit the donut hole after a month, but they did not even know that the plan was not going to cover their drugs until they went in to the store to fill out the prescription.
Roger and Linda Hicks from Bangor, Maine:
Both of their mothers have had a hard time signing up for Medicare Part D. Without the help of Linda and Roger, they would not have figured out how to enroll in the Part D plan. As of September 19, they have not entered the Donut Hold, but Linda seems certain that they are both very close. Both Linda and Roger emphasized that the process for singing up was very confusing and that, had it not been for their help, both of their mothers would not have been able to enroll in the plan.