Judith Pais of Hyde Park struggles with severe COPD and is on oxygen 24/7. She will be waiting to refill her prescriptions until the new year after falling into the “donut hole” coverage gap on Medicare Part D.
“The cost of prescriptions is just out of sight and everything is the bottom dollar and when you get to be my age, you don’t have that much left over,” said Pais.
Pais, 71, gets prescriptions including Spiriva and Advair through mail order and usually pays about $120 for each. Last week, she received a call that the total cost to refill those prescriptions had skyrocketed to $500.
“That’s when I realized I must be in the donut hole,” said Pais.
Medicare drug plans with a coverage gap, called the donut hole, begin when a patient has spent $3,820 on covered drugs. Once you hit the gap, patients pay 25% of the plan’s cost for covered brand-name prescription drugs and 37% for generics.
“I’ve never found myself in the donut hole and this is the first year,” said Pais, who immediately decided to cancel the prescription and used expired, leftover medication to get her through the rest of the year.
“It might not be 100%, what I have, but it will be good enough for one month,” said Pais.
Leigh Purvis, director of Health Services Research in AARP’s Public Policy Institute, said the coverage gap has been slowly closing, but people are hitting the gap sooner and sooner because of sky-high drug prices.
“We are aware that a lot of people are struggling to pay for their prescription drug costs and they are doing things like not taking their prescription drugs the way they’re supposed to,” said Purvis.
“You could have high blood pressure today but it could be a stroke tomorrow if you don’t treat it,” she added.
Purvis recommends patients in the donut hole contact their doctor to explore cheaper alternatives and look into state or federal assistance programs to help manage the cost.
Pais said, “It’s very frustrating because as the elderly, what can we do about it? I can’t get out and be an activist, I can’t breathe going up or down stairs so I can’t get out there and fight.”
Over five million seniors across the country without low-income subsidies fell into the donut hole in 2016, according to a Kaiser Family Foundation study.
Alex Sheff, co-director of policy and government relations at Health Care for All, said the donut hole is impacting many Massachusetts residents.
“No one should have to choose between buying their groceries and affording the medication their doctor prescribed to them and that they need,” said Sheff.
The organization is pushing for a more transparent and comprehensive approach to drug pricing in the Bay State.
“It’s definitely a major concern that folks will forgo medication that they need … and that’s a real danger with the high cost of prescription drugs and high out-of-pocket costs,” said Sheff.
