Medicare’s Donut Hole – Get caught inside and you’ll find nothing sweet

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This is not so much an informative post as one of outrage. Quiet, desperate, stomach-churning dissolution and despair, the smoking embers of what I learned 29 hours ago.

My brilliant stroke of outrage came yesterday sitting in the office of my now Medicare broker when I was told how much my insulin is going to cost me after only four months on my Medicare drug plan. I start Medicare in September. By January I’ll be paying outrageous amounts of money for insulin.

My questions during the meeting were about the workings of Medicare, a four-headed beast – Part A (Hospital), B (Doctors & Tests), Supplemental (Who knows but you need it), D (Drugs), but the questions I left with were societal: Where are we headed as a country that’s making medication unaffordable? Is America a society if it only cares about making rich people richer and providing for those in power?

If you want more in-depth Medicare information as someone with diabetes, please go to Laddie Lindahl’s web blog, Test Guess and Go. Laddie did us all a great service taking us through her learning curve as she approached and signed up for Medicare recently.

This post is about outrage and here’s the bottom line: If you have diabetes and you inject insulin you are going to pay just about as much, maybe more, per year for the cost of your Medicare than a commercial health insurance policy. Why? Because of the unregulated inhumane increase in the cost of insulin over the last decades, particularly the last few years.

For this reason you will get caught, a few months into your Medicare drug plan, in the “Donut Hole” also known as the Coverage Gap. You will be required to pay 35% of the actual cost of insulin each month for the rest of the year once you’re in the Hole. For me, and my insulin doses are low, that calculation is $144/month for my insulin. Contrast the $25 I pay currently on my ACA plan for a three month supply. That’s less than $10/month. For type 2s, who use much more insulin than me, the cost will be much, much higher.

What does this mean beside the fact that Canada is looking pretty good as a stop & shop vacation? That this fight to bring down the twenty-fold increased price of insulin since 1970 is essential. I won’t go into the big pharma, lobbying, middlemen bru ha ha but this is a good article if you’re interested. We on insulin also get caught in the donut hole because there are no generics for insulin. Insulin is a Tier 3 brand name drug, the most costly. Basaglar, which is a biosimilar for Lantus, while not a generic may be lower than a Tier 3 drug, I don’t know.

I wrote “injected insulin” earlier. Now get this – If you are on MDI, Multiple Daily Injections, like me you will get your insulin through Medicare’s Drug plan, Part D. If, however, you use an insulin pump, all the insulin you need for your pump is covered under Medicare Part B – durable goods. Part B pays 80% of the cost of your pump, pump supplies and insulin and your supplemental plan covers the remaining 20%. You pay nothing!

To add to the crazy logic – only tubed pumps are covered in Part B. Omnipod, a tubeless pump, is covered in Part D. But think about it – that means you will still be paying for the insulin just as if you were on MDI. You will still end up in the Donut Hole. Sob, I had a shining hour when I thought well maybe going on Omnipod wouldn’t be so bad, but that dream faded when I learned it was covered in Part D.

I don’t profess to be an expert on this; I told you that up front. I am still reading the plans I selected, and hoarding insulin so I can make it through the first year of Medicare sidestepping the Donut Hole. It’s funny, for years and years people asked me why I don’t use an insulin pump. I always said the truth, I am diligent and disciplined and don’t mind shots, so a pump would offer me more elegant management, but it was not worth the trade off to be tethered to an external device. And now that I use the Dexcom CGM, it would be a second device. Who would have thought Medicare may be the reason I finally go on a pump. It remains to be seen.

While this post has not made you significantly more intelligent about Medicare, maybe you now share a bit of my outrage. Let’s do something. Sign the petition on the American Diabetes Association website to lower the cost of insulin. It takes seconds. Get more informed about what the Diabetes Patient Advocacy Coalition (DPAC) is doing to promote and support public policy initiatives to improve the health of people with diabetes and how you can be part of that.

If you are nowhere near the age of 65 I won’t tell you that by time you get here Medicare will be here to greet you. It may no longer exist. All the more reason for each of us to do something now to make our outrage heard and tell those cyclists up top if they have diabetes and take insulin injections they have little to be smiling about.

7 thoughts on “Medicare’s Donut Hole – Get caught inside and you’ll find nothing sweet

  1. Riva –
    If you are seriously considering a pump, you might want to check which pumps your current insurance will cover and which pumps Medicare will cover. You may have more options if you make your purchase before Medicare chooses for you. Just a thought!

      • Wow! I wonder if your doctor considered a pump medically necessary, you could get it covered. I made the original suggestion because I am due for my second Medicare-purchased pump, the first being a Tandem tSlim, in October 2019. I commented to a friend that I am hoping the Dana RS will be FDA approved by then. He said it won’t matter because he heard that Medicare has an exclusive contract with Medtronic. Keep me posted!

  2. I read this and was so grumpy. I’ve been ‘shopping’ for mom since I’ve been taking care of her. She used to have a pump and the doctors chose to take her off of it (she’s too erratic and had too many lows and it wasn’t working as well as they hoped. She’d had it for YEARS.) Medicare frustrates me entirely. I hate having to pay so much now for the pens and find it crazy they are more than my own bottles of insulin sometimes. I can’t imagine how much money is dropped in one unit of insulin. Stupid.

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