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Print | Email | Share | Comments (31)

A Reader Falls Through Medicare's "Doughnut Hole"


Jan 23, 2008

Editor:  I am an enthusiastic reader of your magazine. I appreciate the number of times you have tackled some of the bigger questions of diabetes management that others have ignored.

Here is one issue that is of great concern to me: I have been diabetic since 1947, using insulin for just about all of those years. The insulin was covered by some type of medical insurance, including the five years that I used a pump.

Because of site infusion problems (lipoatrophy and hypertrophy), I moved on to insulin pens and am now injecting long-acting insulin once a day and boluses with meals.

This worked fine even into Medicare years, but now with Part D coverage and the "doughnut hole," I find myself with no coverage options. Imagine my dismay to learn that Medicare will cover the cost of insulin delivered through a pump, as well as all the other expenses incurred by pump users. I continue to pay for insulin in cartridges and fall into the doughnut hole each year.

The cost of supporting syringe or pen users is miniscule compared to pump users. Has no other reader complained about this? Would you address this in a future issue?

Thanks,

Alice Allen Erie,
Pa.

Editor's Note: We welcome comments on Alice's plight.


Categories: Diabetes, Diabetes, Health Insurance, Insulin, Insulin Pumps, Letters to the Editor, Pens, Syringes, Type 1 Issues



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Comments

Posted by Anonymous on 24 January 2008

How is it possible to reach the donut hole yearly using the pen? This person could use the cheaper and re-usable syringes. She has to have lots of other expensive medications to reach the donut hole this way, in which case perhaps she should consider using generics.

Posted by Anonymous on 24 January 2008

Consider changing health/drug companies. Do an analysis of costs. Contact the company direct and ask for patient assistance fund money.

Posted by Anonymous on 24 January 2008

As a healthcare provider, I know that diabetes is a very expensive illness to treat correctly. It requires many medications, as you often treat high blood pressure, high cholesterol, neuropathies, along with multiple medications and insulins for the diabetes. There are not always generic medications available. The newer insulins like Lantus and Humalog, which have revolutionized the way we treat diabetes, are not available as generics. The pens are a convenient delivery device if a person works or volunteers, as they do not have to sterilize an insulin vial, withdraw insulin and administer it. All they have to do is dial, click and poke. Let's say this person has to take Lisinopril for high blood pressure, Lipitor for high cholesterol, Gemfibrozil for high triglycerides, Levoxyl for hypothyroidism, Prempro for hormone replacement, Actos for diabetes, Metformin for diabetes, and Lantus and Humalog pens for diabetes. She also has reflux and takes Nexium, neuropathy and takes neurontin. It is quite easy to hit the Medicare "donut hole." Some of the pharmaceutical companies offer discount cards for seniors to use along with the part D plans. Also, if an individual makes below a certain amount of money on social security, there may be programs available to help pay his or her premiums for both Medicare parts B and D - check with your local social security office.

Posted by Fran on 24 January 2008

I don't usually comment on any internet web site but had to have a say about this. I am 76 1/2 and retired in January 2006. I worked much longer than required to save and prepare for retirement. I enrolled in Part D in 2006 with the provider recommended by my insurance agent. I paid a higher premium in order to have coverage during the "gap". That was not an option in 2007 or 2008. I take meds for hypertension, thyroid hormone replacement, cholesterol control, potassium replacement, and six injections daily for diabetes. I take generics when they are available. I stopped taking some drugs to reduce the costs of my meds. One third of my SS benefits go to pay for medicine. I hit the gap by April or May and do not come out until December. I use what you refer to as the cheaper syringes.

Posted by rosiolady on 24 January 2008

Medicare USED to pay for insulin. Now it is only partially covered under Part D. There is a good-sized co-pay required. I use Humalog insulin in my insulin pump. With a vial of Humalot costing around $95, you can imagine that with my other medicines (yes I have some for hypertension, and a few other things), I too fall into the Donut Hole by mid year. Right now I still have credit, which is diminishing as the costs of buying my own meds goes up and up, but I foresee a time, all to soon, when I will probably go bankrupt unless something changes. When I have no more credit available and still not enough money to cover my medications, then what?

Posted by Anonymous on 24 January 2008

It is all too easy to fall into the donut hole, I did it in 2006 and will again this year. And that is with no insulin expense, my endo provides my insulin in vials and I refill my cartridges from the vials. Well, my humalog, I use levemir from the vial. We diabetic seniors are a very lucrative market, we take multiple medications, some of which are lifesaving, and many of which are not available in generic. I use generics, I use Costco and WalMart off the insurance; I am an informed consumer. But this year I will probably be put on tamoxifen, which will, by itself, use up my drug allowance. I have written my senators and representative about this hardship, I have to much to qualify for help, yet my income cannot stretch to cover the meds in the donut hole. I used a zero percent credit card for 2006, switched to another one when it ran out, and am still paying it off. Trust me Alice, there are many of us.

Helen Mueller, who needs to register.

Posted by capand andy on 25 January 2008

My sympathies go out to Fran and rosiolady. I too fell into the donut hole, after five monthes of coverage. I was in the hole for six months, and then my coverage kicked in again- for one month. It's now a new year, and so it starts all over again. I watch my diet, use Byetta and glipizide, and finally have pretty good control. I use generics whenever I can, but I am on a number of other medications for other medical conditions and it adds up fast.

Posted by Anonymous on 25 January 2008

Mom mom has to take several different meds for high blood pressure, cholesteral and of course the Lantus and Humelog. She also has to use the Advair inhaler... she hits the donut hole by mid April. Something's just not right. These medication as so expensive, and used by so many that just can't afford them. We as a country have got to do something to find a solution

Posted by Anonymous on 28 January 2008

A friend and myself will be medicare eligible in a few months. How can you find out what is covered and what is not? Back a few years I know medicare did not cover pumps for type 2. I do not know what has changed and what has not. How can I get information on what medicare covers and what it does not. She is type 2 and I am type 1.

Posted by Anonymous on 29 January 2008

A friend and myself will be medicare eligible in a few months. How can you find out what is covered and what is not? Back a few years I know medicare did not cover pumps for type 2. I do not know what has changed and what has not. How can I get information on what medicare covers and what it does not. She is type 2 and I am type 1.

Posted by Anonymous on 29 January 2008

A friend and myself will be medicare eligible in a few months. How can you find out what is covered and what is not? Back a few years I know medicare did not cover pumps for type 2. I do not know what has changed and what has not. How can I get information on what medicare covers and what it does not. She is type 2 and I am type 1.

Posted by Sharon E. on 30 January 2008

As a diabetes educator working in a large hospital I see pts having to make life or death decisons re meds every day. We are in big trouble in this country and I urge everyone to make this a campaign issue! Our system is broken and people are dying. Its time to fight back! The goverment could have used the billions in economic rebates to help with health care! And they expect us to go out and buy big screen TV's???

Posted by ricklude on 1 February 2008

Sharon E.,
Yes, the system is broken but, NO, it dosen't need a new "freebe hand out" one either!

Government HAS TO keep out of free enterprise and worry more about governing, rather than getting into the health care profession/business!!!!! Fix the garbage systems and plans they have in place already!!!!!

Besides which, there are other ways besides depending on the government ie. tax payers, inorder for this person/patient, and others, to get their meds!

Posted by Anonymous on 1 February 2008

It appears some of the comments here are cruel or ignorant, or both. I too use a prefilled pen and they are very expensive. With poor eyesight, I need to hear the clicks for proper dosage. The doughnut hole idea was created by the insurance and drug companies to put off universal health care. As a country we spend the most money on health care in the world, yet the world health organization rates our health care 37th in between Slovenia and Costa Rica. If we were allowed affordable drugs, we would be more inclined to use them for prevention until waiting for catastrophic illnesses while attempting to avoid the doughnut hole. If the Federal government doesn’t want the job of negotiating drug prices, at least they should allow Medicare to do it. The VA does it; France, Canada and many of the Countries ahead of us in the ratings do it. Why can’t Medicare do it? Corrupt politicians and wealthy and powerful special interest group influence is the reason. If it were not for my VA meds, I would be in the hole by March of each year. For the last two decades we have lost our way in this country because both Bill and George think they are Kings and we are their royal subjects instead of their employer. The Clintons and Buses royalty have controlled this country too long. It’s time for a change. My heart goes out to all of you

Posted by Anonymous on 4 February 2008

I just figured out what falling into the donut hole means for me. It means that after working for all of my life, I'll be bankrupting myself in 3 years to pay for the medications I need while in the hole. I can't find cheaper meds and drug assistance programs won't help me since I earn just above the income guidelines. (They just don't consider that if you pay for the drugs, you will be eligible according to the guidelines). I don't know what to do - short of robbing a bank and with my luck, I'd get caught, be sitting in a prison, and asking the system to pay for my meds. Yes, I'm depressed - now I can't afford to buy the meds to cover the depression.

Posted by Anonymous on 6 February 2008

As suggested by Foodpolice, I looked up "Medicare Coverage of Diabetes Supplies and Services" and read on page 10 "Medicare will also pay for the insulin that is used with the insulin pump." Seems clear to me!

Posted by Anonymous on 8 February 2008

My mother always reaches the donut hole mid year. We found a Medicare Part D prescription plan that provides coverage through that period. We had to change to a different one this year because the previous one changed.

Posted by jools on 10 February 2008

hello to every one on this diabetic site,i julia from down under have had diabeties since i was 9 1\2 years old. i am now 49yrs. i have every thing a diabetic can get. over the years of being one, i have been very disapointed with no cure yet. the doctors say i am very welled pickled on the out side and should of been dead 10 years ago. ha ha i will not let this disease get me down or take me away from this planet. the one thing that i do not like about doctors is the way they put you in a no fix basket and do not care how we feel on a dailey basis and how we are exspected to just get on with our lives. there is never any help with what ever we need to make our days easier. i have a big problem with charcot foot. my feet get so sore, that by the end of a day i have to put my feet up. so when i saw a doctor called dr. sands over in america in manhatten i think that will reconstruct feet instead of just cutting them off, i was really excited. can i please have an address to try and contact him to see what he could do for me. i hoe to be here still for a very long time and hope one day soon i will be asked to try out a cure and be cured while i still have many years to live on with out any mor diabeties. regards julia from down under.

Posted by Anonymous on 1 May 2008

I keep listening to 30 second sound bites on television from our current presidential candidates. They all are sounding the same. I can't afford for them to win, get in office, and then sit there for another 4 years. I need help now!

Posted by Anonymous on 11 June 2008

Ah, the realities of being a diabetic on Soc Sec Disability have finally appeared!
I too am in the DONUT HOLE. But, a more realistic word for it would be BLACK HOLE OF DEATH or MEDICARE's method of clearing out the Soc Sec dependent society.
I need 8 vials/mo of Humalog and 8 more of the blended variety to live. Cost is about $125/mo, though, Ive found places that will sell it for $90 if I buy a 3month supply of all 16 vials at once.
Then there are Canadian pharmacies with prices from $30> $50. But, there you face two risks: counterfeiting, and confiscation by US Customs.
Well, considering that I only get $1200/mo to live on, and that Im $250 beyond the limits for ASSISTANCE programs, I guess life will be at an end when my months backlog runs out.
Whats ironic is that the people at Soc Sec pass me to Medicare; I asked to get my payout reduced, to no avail. And, Medicare says that the law says all my insulin is paid for by the govt and that a DONUT HOLE doesnt affect diabetics. Then they give me resources that dont apply, but probably to pass me on.
But, when I called HUMANA, the supervisor admitted they couldnt help and that they were losing many patients each year due to no longer taking meds.
In the past I got help from LILLYCARES and NOVO. But, they no longer help anyone who is in Medicare.
So, guess this will be my final comment on the topic, since my next step is into a BLACK HOLE.

Posted by mpmyers on 17 June 2008

This is the little know facts regarding this "improvement" in Medicare. However, there is more to it. Medicare Part D should be selected, not as much on what the supposed benefits are, but what the benefits are for the drugs one knows they take. Some of the comments made on this are understandable, but not so much accurate.

I would encourage a person to start on the Social Security website, which will show you which plans in your area will serve you best.

Posted by mpmyers on 18 June 2008

I don't appreciate my comments being edited out so as to change what I wrote. If you are not going to post all of it, you do not have my permission to post any of it. Remove my comment above or replace it with my entire post.

Posted by jerryjosie on 11 July 2008

There are Prescription assistance programs that help with this. Use a web site such as https://www.pparx.org/Intro.php, to help you find the addresses, fill in an aplication and include a personal letter.

A lot of the programs that stopped this in 2006 are beginning to help again in the "donut".

Check with your Area Agency on Aging, or state department that deal with disability and aging and ask for help dealing with benefits.

There are programs available, and by asking the drugs companys, they may reconsider the programs, as they relate to Medicare D and the "donut". Some of the company's have already changed..

There is help and there are ways of post-poning, or avoiding the gap..

Posted by Anonymous on 5 August 2008

i too have reached the donut hole (already) 6 months into the year..mostly due to humolog for insulin pump as with medicaire and the hmo i have medicaire doesnt pay the insulin cost...each plan is different and we have to spend hours and hours researching..what covers the insulin but not the pump maintenance...or visa versa..going back to shots is not an option, not to mention mental illness medication / forget our medications and be off balance and admitted to another psyche hospital

Posted by Anonymous on 5 August 2008

what will happen eventually is that you will be in the hole within a month or two ..then what....we need more generics offered to us than non generics...offer us old medicine the new stuff doesnt work anyway...but pharmacutical companys are in cahoots to offer high priced drugs...

Posted by Anonymous on 24 September 2008

I noticed comments that it is "cheaper" to use syringes with vials of insulin rather than pens with cartridges of insulin. Keep in mind that most insulins will expire after 28 days of their initial use. A vial contains 10 ml (equivalent to 1000 units) of insulin. A user will often have to toss out most of an unused vial. A cartridge holds 3 ml (300 units). There is a savings for those who can use up the entire cartridge.

Posted by Anonymous on 6 October 2008

I have just paid $165 for 5 cartridges of insulin for my pen, signaling that I am once again in the donut hole ( and will pay full price for all prescriptions until year's end). Does anyone out there know for sure - would Medicare pay for this insulin if I were on the pump?

Posted by Anonymous on 9 November 2008

Now I have just paid $170 for a 5-pack of Novolog pen insulin, up $20 from last time! Will this never end? (I have been in the donut hole since September.) What can be done?

Posted by Anonymous on 7 February 2009

Yet another Novolog pen refill purchase - this time it cost $210.

Posted by Anonymous on 25 February 2009

Last year was the first time my wife and I went into the donut hole. Our monthly drug costs at that time was around $1400 per month. Changing to generics we have reduced this amount to around $700.00 per month. This is still too high for someone living off of retirement savings and social security. The current arrangement under Medicare for diabetics is unacceptable and shameful. Do not bury your heads people, please write your congressmen. As the "baby boomer" population experiences Medicare's donut hole, eventually it will become clear to our legilative elite that this situation must be altered.

Posted by Anonymous on 23 June 2011

When will there be a "generic" to replace insulin? Until that day, all insulin-dependent diabetics are doomed to the donut hole!


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