Medicare and the "donut hole"


I have been on the same medications for years. The dosage has also been unchanged. A few years ago, I reached the gap very late in the calendar year. The next year, the gap came sooner but I hit the catastrophic stage 4 in November. Each year I hit the gap sooner than the previous year and only had one year that I reached the catastrophic stage. Well, February of 2019 was a BIG shock because I hit the gap (donut hole) already.

I thought it was said they fixed this problem and the fix was being phased in each year to help. Looks like the exact opposite to me. Each year it has gotten worse, not better.

Anyone else in the USA on a Medicare drug plan that is having gap issues?

I am OK with going into stage 3 in February if I also go into stage 4 in the next couple months, spending the rest of the calendar year in the catastrophic stage. Yes, I know the dollar amounts for each stage but they use different money amounts to calculate the dollar amount in the various stages.


I would contact my Area on Aging they have specialists in this field. I know here ourAgency can do three way phone calls to see how this is all working for you. Do you take high costs drugs? Would your 8ncome be that you would qualify for assistance from the drug company with your doctors help? Best of luck. Nancy50


Do what I do–get drugs for FREE. 3 of my meds are a bit expensive, so I contacted each of the companies for assistance. Out of the 3, I could qualify (income-wise) for free meds from 2 of the companies. Can’t beat drug assistance programs when the cost is ZERO.

Also, I get all my insulin from my endo’s office–all free. I’ve been doing that for years. Doesn’t matter if it is Humalog, Novalog, Lantus, pens/vials/whatever. Free for the asking.

I haven’t ever been in a donut-hole, but I DO love donuts!


I had the same problem and my easiest solution was to drive to Canada every 8 months or so and buy my Humalog and Lantus there over the counter for 1/10th of the retail US price. By doing that I no longer hit the gap.


Part of this is explainable by the higher drug costs. The percentage the patient is required to pay during the coverage gap has slowly been shrinking but the prices of drugs has been greatly increasing. Back when they first starting “narrowing” the patient portion during the coverage gap, the pharma company would basically give a 50% discount and the patient would have to pay the other 50% (back in the beginning the prescription drug didn’t have to pay anything or very little). So if the insulin cost $100 a vial and you needed 3 vials ($300) for a thirty day supply, the drug company would cut that price in half and the patient had to pay $150 per 30 days.
Currently, I’m not entirely sure what the coverage gap is doing. Originally, by 2019, it was the pharm company would discount it 50%, your Part D would pay 20%, and the patient would pay 30%. Medicare’s website ( says that in the current calendar year (2019) the pharma company discounts it 70%, patient pays 25%, and your Part D pays 5% (hmmm…are we surprised that their portion got smaller??:face_with_raised_eyebrow: )
(This is all brand name, not the generic).
So that insulin vial that used to cost $100 a vial is now $250 dollars a vial and those three vials are equal to $750 per 30 days. That means your 25% is going to equal to $93.75 (which somehow seems a lot less than what people are actually paying so I wonder if my math went wrong somewhere or if there is something rotten Denmark.) (No, I’m not making disparaging remarks about people who come from Denmark…It’s from Hamlet…:yum:)

Anyway that is the general principle. (Something still seems really off).

Same is true for getting in to the coverage gap too. Drug costs are higher so you get into the coverage gap faster.

When did you hit the coverage gap last year? Something seems really off…I wonder if the pharmacy has been processing your test strips through your part D.
Locally, I have had some sneaking suspicions about some of these plans. They want people to change the glucose meter from meter “A” to meter “B”. Typically (at least in my neck of the woods) most Medicare patients are exempt from dealing with the whole “preferred glucose meter” that others deal with. After some investigating I found out that a person didn’t HAVE to be on the “preferred” meter. What you had to do was a “prior authorization”. Then the plan will deny the coverage under Part D and approve it under Part B (which is where it should have been in the first place). It is a hard thing to explain because it is probably one of the most bizarre things. (Ironically, you have to do the same thing too for these plans if a person is a Medicare patient on insulin through an insulin pump.) You have to do a “prior authorization” so that the plan will deny it under Part D and cover it under Part B. Not many people necessarily know this. Many would just have their provider change the meter to the one they have been directed too and never know. I’m only guessing that if that was done that the plan would run it under the Part D portion. I’ve never had the circumstance where I have found out for sure.

Bottom line, you many want get some sort of “statement” (many plans will send it to you if you ask) that shows what got you into the “donut hole”.

@Dave44 is correct. The pharm companies offer assistance for Medicare patients in the coverage gap. They can be quite generous in their criteria so it is worth looking into. Eli Lilly (the makers of Humalog, Basaglar, Trulicity, to name some) financial criteria is an annual gross income (Alaska and Hawaii have to call to get their income rates) for one person is $48,560 or two people it is $65,840. You have to spend $1,100.00 on prescription medications in the calendar year (just yours not yours and a spouse’s) before they can assist. Everything you paid at the pharmacy for prescriptions counts. Deductibles (for prescriptions), copays, etc.

Lilly is by far the most generous in their financial criteria. Last year they greatly expanded it. Novo Nordisk and Sanofi Aventis have similar programs (though last I checked Sanofi you have to have spent 5% of your gross income on prescriptions before you can get assistance).

You can be on it until the year of the year.

Hopefully this information helps.


for the two prescriptions that I get using the patient assistance programs there is no requirement that I have to spend $1,000 on medications before I qualify


Interesting…:thinking::thinking:It could possibly vary depending on the program or medication or your income bracket. I know some programs, like Sanofi Aventis, which has the 5%, do their own checking. It also may depend on where you live and the rules for your area.


Pfizer and Takeda


That makes some sense…I believe both these companies use a different style of patient assistance (I think it more like a foundation but I could be wrong). There are a few programs out there that you don’t have even be in the “donut hole” to get assistance (if you qualify). It depends on how the patient assistance program works. I don’t know all the ins and outs of it but I believe if the money it is like a non-profit organization that essentially “pays” for your things when you can’t then there is no minimum limit. When it is the company just giving “free” supplies than there is a “spend down”. I believe that is the general principle.


Donut hole is irrelevant for the 2 I mentioned


I just came across that with another company…was news to me. It all depends on how it is handled. I wish the insulin companies would do it that way. I complain to them constantly about the “spend down”.


I read where Lilly is coming out with a insulin that will be 1/2 the cost of the current insulin.


Its the same insulin, in new packaging and is still overpriced,but whatever. They are trying to appease the government but I hope their little charade doesn’t work. Diabetics aren’t happy and I don’t blame them.