I just rolled into the "Donut Hole"...yikes! (plan, doctor)

[AZgarden]

For many months I have taken Linzess at a cost of $35 for a 30 day prescription. It's for IBS and it helps some. In Nov., I went to get it and it was $68 and I was told I had entered the donut hole. Never been in it before. All meds were covered using insurance, mostly tier 1 and 2 with no problems.

So yesterday, I went to get the Rx, had to pay $125 for it. Outrageous. Why would a drug keep increasing each month, while in the donut hole? Anyone know? I was told by insurance that the meds would all go back to original after the first of 2022. Is this true? The pharmacist's comment was "maybe."

[ManApplet]

Remind me to never get sick nor old

[Angie682]

The cost of medications can vary. I work for an insurance company and several of the major pharmacy vendors have indicated the costs for medication can fluctuate just like the stock market does.

[reed303]

Originally Posted by AZgarden

For many months I have taken Linzess at a cost of $35 for a 30 day prescription. It's for IBS and it helps some. In Nov., I went to get it and it was $68 and I was told I had entered the donut hole. Never been in it before. All meds were covered using insurance, mostly tier 1 and 2 with no problems.

So yesterday, I went to get the Rx, had to pay $125 for it. Outrageous. Why would a drug keep increasing each month, while in the donut hole? Anyone know? I was told by insurance that the meds would all go back to original after the first of 2022. Is this true? The pharmacist's comment was "maybe."

Here is one possibility.

While you were paying $35, you most likely were in Stage 1, paying your plans co-pay for a Tier 3 drug. (My plan would charge $47). When you hit Stage 2, the $68 was owed after passing the threshold for Stage 2. The $125 charge may be your new Stage 2 co-pay .

Next year you should start over in Stage 1 at what ever your plans 2022 Tier 3 co-pay is but subject also to a any deductible.

See page 82 and 83 of https://www.medicare.gov/media/10991 for more details.

Medicare doesn't use the term "donut hole". They call it "Catastrophic Coverage".

Also are you aware, according to https://www.goodrx.com/linzess , the average List price for Linzess is about $550 ?

[flashlight]

that middle price might be because it was partially in the donut hole.

what did you pay before you met the deductible?

[AZgarden]

Originally Posted by reed303

Here is one possibility.

While you were paying $35, you most likely were in Stage 1, paying your plans co-pay for a Tier 3 drug. (My plan would charge $47). When you hit Stage 2, the $68 was owed after passing the threshold for Stage 2. The $125 charge may be your new Stage 2 co-pay .

Next year you should start over in Stage 1 at what ever your plans 2022 Tier 3 co-pay is but subject also to a any deductible.

See page 82 and 83 of https://www.medicare.gov/media/10991 for more details.

Medicare doesn't use the term "donut hole". They call it "Catastrophic Coverage".

Also are you aware, according to https://www.goodrx.com/linzess , the average List price for Linzess is about $550 ?

Yes, I know that Linzess is a very expensive drug. I was astounded when I found out that my UHC would cover it for just $35 a month co pay. So I happily took it with no concerns. Hopefully, it will go back to $35 Jan. 1. If not, I will have to try something else.

[reed303]

AZ,

Are you getting EOB's (Explanation of Benefits) from your Part D plan ? EOB would show and explain when and why you "fell into the donut hole". If you are not getting any EOB's (generally 1 for each Rx fill) , you should be. Call them if not.

[CharlieAllnut]

The four stages of Medicare Part D coverage are:

Stage 1 - annual deductible
Stage 2 - initial coverage
Stage 3 - coverage gap (the “donut hole”) - you pay 25%
Stage 4 - catastrophe coverage (you pay 5%, the rest is courtesy of your Uncle Sam)

Paying $125 in the donut hole for a drug that costs about $500 retail makes sense, as that would be 25%.

On January 1, everything should reset and you would start with your deductible and then the initial coverage stages again.

[GWoodle]

Originally Posted by AZgarden

For many months I have taken Linzess at a cost of $35 for a 30 day prescription. It's for IBS and it helps some. In Nov., I went to get it and it was $68 and I was told I had entered the donut hole. Never been in it before. All meds were covered using insurance, mostly tier 1 and 2 with no problems.

So yesterday, I went to get the Rx, had to pay $125 for it. Outrageous. Why would a drug keep increasing each month, while in the donut hole? Anyone know? I was told by insurance that the meds would all go back to original after the first of 2022. Is this true? The pharmacist's comment was "maybe."

This is how a Part D plan works. In a year there are 4 prices for the same prescription. If you take anything else it is added to your cost. The pharmacist must be unfamiliar with how your plan works. Your doctor may be clueless. You can ask if there is anything else to try.

For 2022 I suggest you keep a notebook for if/when you get any prescriptions. You will need the Full Retail Cost, maybe $500?

At your pharmacy they should have a record of all your prescriptions for the year. Get a copy so you can see everything added together. Maybe you got $6000 worth of meds for $500?

[carnelian]

I hate the term donut hole...call it anything else.

Its an attempt to sugarcoat a bad situation. You ran out of dough.