Medicare’s Part D Doughnut Hole Has Closed! Mostly. Sorta.

The drug coverage gap was widely loathed, but the new scheme may still leave some older Americans holding the bag.

Comments: 163

  1. Why do we fleece our own? I was in another country working with their private health system. Same goods "made in the USA" and yet the prices were half of what you can get in the USA. Universal with none-of-the deductible/out-of-co-insurance health for all!

  2. @MW We are indeed being fleeced. Washington needs money to stay in office and the drug companies need high noncompetitive prices. They have made a deal.

  3. @MW Money runs everything with no regard for morals or integrity. Boeing made that quite clear recently.

  4. The US (including Medicare, with the exception of the VA) is forbidden by law to negotiate with drug companies, unlike most other countries. So we make up the difference that Pharma loses in other countries. If company X goes to a country - say Nigeria (it could be anywhere) - and wants to sell its drug, the Nigeria says “ok, this is how much we will pay”. Then there is a negotiation. If the drug is really, really needed for some reason (that may be technical or political) then the country goes back and forth until both parties get a price they can live with. Small countries have very little leverage no matter what while large ones have lots. But in the back of a US drug company mind is that they can always make up for lost profits by jacking up prices in the US. So it is unlikely that the drug companies would accept much lower profits if the US wrestles it’s drug costs down; it IS likely that the rest of the world will simply make them up.

  5. What Counts Toward Exiting the Coverage Gap: When you are in the gap and paying 25% of brand-name drugs, your spending counts toward exiting the gap. The manufacturer’s drug discount of 70% also counts and will help you exit the gap faster. There are two things, though, that don’t count toward closing the gap. These are: The amount that your drug plan pays toward the cost of the drug, which is 5% in the gap The amount that the drug plan pays toward the pharmacy’s dispensing fee, which is 75% of the fee in 2020 Keep in mind that there are other things that don’t count toward reaching the catastrophic limit, which are your plan premium and also what you spend on any drugs that aren’t covered by your Part D plan. You should also factor in the price of brand name drugs that has no generic substitute. The Part D coverage inside of a Medicare Advantage plan works exactly the same way that standalone Part D plans works. Some Part D companies and Medicare Advantage companies might offer coverage of certain medications in the gap. However, this is almost always coverage of generic medications and rarely brand name medications. This doesn’t really help a great deal since the drugs that cost so much in the coverage gap are brand name drugs, usually not generics.

  6. @USNA73 Most insurers just paste one of their existing part D plans onto their Medicare Advantage plans.

  7. However, the manufacturer of one of my tier 5 drugs came out with a generic, however, the generic was also put in the tier 5 category. Not much savings, due to the original manufacturer also making the generic. So where is the competition which should lead to lower prices?

  8. @Jazyjerome Horrible. The ultimate Catch-22. Criminal behavior.

  9. I will begin collecting Soc Sec. in August. I have 4 Auto immune diseases. I needed Brand named medication is $6,600 a month and of course there is Insulin and supplies for my Type I Diabetes. Something needs to be done or I likely won't be living very long.

  10. From its inception, Part D was ripe for exploitation by both the insurance companies that wrote the annually morphing policies and now the plethora of the coupon companies with their own sign ups, some with fees. Good Rx has already undercut my Part D coverage. This especially the case when you needed a drug that you did not need when you signed up so did not list it. Traditional Medicare with a Part F supplemental plan provides access to medical care anywhere and rarely if ever results in surprise expenses. Just simplify Part D, clamp down on big pharma's unaffordable prices for many drugs and take the business driven complexity out of it. Right now, Part D feels a bit like a scam.

  11. @AGoldstein Yes, but Part F policies are no longer available as of 2020 to anyone born after 1954. Well, that's what I read when I signed up for a Medigap plan for the first time this past open season. I did choose a Part F plan.

  12. @Ann - Yes, no Part F for new applicants but in 2020, you can get Part G where the Part B deductible is only $198. Just another example of how the benefits of Traditional Medicare are being further complicated and eroded.

  13. @Ann we have Part G and there is little difference. We pay for the first $185 yearly deductible and have full coverage after that.

  14. To really appreciate the pharmaceutical industry's ability to manipulate the government for additional profit, look at the history of Part D. For decades Congress had wanted to add drug benefits to senior healthcare, always opposed by big Pharma. That ended when the new bill agreed to NOT negotiate prices. The doughnut hole was added to reduce the unbelievable high cost to the government. Then, Billy Tauzin, the GOP whip, who probably did more than anyone else to get Part D passed, decamped to a cushy job leading the pharmaceutical industry's DC lobbying group.

  15. @John Actually the donut hole was a sabotage mechanism of the conservative side of the GOP (this was a GW Bush initiative if you will recall). They wanted to "make people think twice" about the price of drugs, so they said, whatever that meant. I also recall that some of us were fighting to get oral cancer drugs covered under part D - if you went to a doctors office and sat in a chair for an infusion your drugs were covered. If you swallowed a pill, they weren't. really US healthcare is ridiculous on so many levels

  16. It will take me about 10 minutes to zip through the deductible, doughnut hole, etc. I expect to pay more than $7k this year for my main MS medication. No generic available. And no cheaper alternative, either.

  17. @Naomi So we just hand over our lifelong SS benefit to drug manufacturers.

  18. My Humana supplemental drug coverage went from $17/mo. to $24.40, and now it's $57.70. I'll be changing my coverage but can't until next year, my fault for working and having numerous work deadlines, and then completely missing the deadline to change my coverage. the cost has more than tripled.

  19. @Dominique Humana played us. When I investigated the Part D plans, including the 57.70/mo plan they'd assigned me, I was told Humana changed all the plans this year. In doing so, they arbitrarily changed me to the expensive plan and weren't required to tell me! The plan I'd had previously actually changed to a $13.20/mo policy. I took that. Seems criminal and unethical.

  20. That can’t be right. There is no inflation. Just ask the Fed.

  21. Humana pulled that same scam on me. Bumped up my 14.00 plan to 27.50 last June, then informed me it was going up to 67.00 in January. I shopped around in December and found the exact same plan for 13.00 so I dumped them. I don’t even use the freakin’ plan most years and I’ve never even met the deductible so they never paid a penny out on me.

  22. After all these years, my jaw still drops when I'm reminded that Congress prohibits Medicare from negotiating prices with drug providers. This senseless corporate welfare provision, a huge boon for drug companies, carries enormous costs for America's senior citizens.

  23. @Ken Morris That would be a “Republican Congress”.

  24. @Jack Smythe But it was in Clinton's 2000 proposal

  25. @Jack Smythe Thank you.

  26. This year, my health insurance company established a so-called deductible on level 3,4 and 5 drugs. When I attempted to order a level 3 drug, I was told that I must first pay a $415.00 “deductible” in addition to the cost of the drug. After that,I would pay only for the drug. How is this a deductible? To my mind, a deductible, would gradually be reduced as I ordered medicine and at some point during the year, it would be satisfied. This year, I must pay the entire deductible out front. This is not a deductible as I’ve heretofore understood it.

  27. A deductible has always been is you satisfy the first $415 and then you have a copay. Lets say you had a car accident and your deductible was $1000. If the bill was $1200, you would pay the first $1000 and insurance would pay $200. I believe you are thinking of maximum out of pocket.

  28. I always thought of a “deductible” as an amount to be taken off the top of my cost of services or products, like car insurance or medical insurance. But I, too, was shocked this year when my Rx provider told me it’s not applied to the cost of prescriptions. It’s really a fee paid before you fill any prescriptions.

  29. @Cathy Kuchta Exactly!

  30. If we had M4A so that costs could be spread across the whole population and every citizen could have access to regular preventable health care from the time they were born; and if the government could do things like negotiate drug prices with Big Pharma, then people's health would not be based on whether or not they could afford to see a doctor or buy insulin. BTW, insulin prices in the United States nearly doubled between 2012 and 2016. Why? And why does a vial of insulin cost $320 in the U.S. and the same vial cost $30 in Canada? One answer is that the Canadian government can institute price controls on the cost of medicines. I still don't understand why so many in the U.S. are opposed to M4A. Do these people really love their premiums, their high deductibles?

  31. @JH A lot of people oppose "M4A" because it is for "ALL", not just the people who deserve it. It is amazing to me the number of people willing to cut off their nose to spite their face. Others oppose it because it is gasp "socialism". Others simply because Faux News tells them to.

  32. Curious how Medicare is unable to negotiate drug prices while foreign governments can. As a results I am sure on a macro basis manufacturers objective is to raise the average overall price paid for per pill, capsule, etc. Said differently, higher US prices are in some ways subsidizing the pricing in other countries. Allow the US to negotiate and average overseas prices will rise as they should, while US prices decline. Unbelievable how the US government shoots itself in the foot on behalf of its citizens.

  33. @TVM As I understand it, Medicare does negotiate prices for its Part D participants, but was prohibited from negotiating prices with insurance companies generally (i.e. the general public). Hence the uproar about sky-high retail pricing. Is this correct?

  34. @Wine Country Dude No. Under Part D, the plan sponsor (in my case, conveniently, CVS--the largest buyer of drugs) negotiates with the manufacturer.

  35. I have fallen into that hole more than once. And, my insurance company even charged me for a prescription a price as if I were in the hole although I was not. Arguing with the "support" personnel located somewhere far, far away from the US did not help at all. The other very odd thing about the boundaries of the hole is that the entrance is calculated base on the TOTAL cost of the drugs, what the insurance pays and what the subscriber pays. However, exit from the hole is calculated based on the subscriber's out of pocket costs. Say the entry to the hole starts at $3,850 total cost of which I might have paid $1,800. Suddenly my exit needs $3,000 more I have to pay if the exit is at $4,800. Insurance is a risk-taking business. But, the insurance companies want no part of that risk. I don't see them returning some of the premiums to the subscribers if they have not used any drugs, but they have no hesitation to push those who need a lot of prescription medicine under the bus. I guess, the pharmaceutical and insurance companies need the extra income to maintain their never-ending TV commercials.

  36. @Cemal Ekin This is very helpful. It's never been clear to me whether entry into the hole depended on your out of pocket cost, the insurance plan's negotiated cost, or the retail cost. Having only encountered the hole once, I didn't explore it. It would help if the article clarified this going forward. Is emergence from the flat-fee regime into the 5% open ended regime calculated again, against the individual's out of pocket costs, or something else? Finally, is the 5% calculated against the insurer's negotiated cost, the individual's out of pocket costs or, shudder, the retail price of the drug?

  37. It is to late to change Part D for 2020. However I remember reading a NYT article that explained the Medicare Part D web site was worthess, useless this year so I gave up trying to get a insurance that would cover my meds . It is also clear that when Medicare Part D became available the drug companies began raising their prices especially for any non-generic drug. I wondered why t George Bush backed part D and its now very clear that it has greatly increased profits for his friends . Also most people don't realize that generics are NOT equilivant to brand drugs and they are not even required to be the same strength as the brand drug. The fillers are also questionable as they come from many countries and no one knows what's in these drugs. I would never use generics and many cardiologist find they are dangerous especially for people with arthymias that require exact dosing.

  38. @Chelsea Sorry to tell you this and ruin your day. But Part D is -- with a few tweaks -- pretty much the way President Clinton proposed it in 2000

  39. Big Pharma has the inherent tendency to invent new needs, disregard all boundaries and turn Medicare Part D into an object for sale and big profit. To fix this problem, we might nationalize the pharmaceutical industry & mandate that drug companies be converted to non-profit public service corporations that serve the public interest rather than being used by 1% investors for unlimited profit. Another option is to establish Medicare for All health insurance that allows a single purchaser, the government, to directly haggle with drug manufacturers over drug prices. This would bring U.S. drug prices in line with those of other high-income countries, who pay much less than we do for medications. Also, we need comprehensive reform in the way we produce new drugs with a public path for drug development and clinical trials that would produce new medications that remain forever in the public domain. Drugs would then function as real social service/health goods, not profit-producing commodities. Nobel Prize recipient Dr. Bernard Lown of the Harvard School of Public Health sums it up nicely: “One may only hope that Winston Churchill’s quip will soon be realized: ‘You can always count on Americans to do the right thing, after they have tried everything else.’ The United States has tried any number of bad solutions for providing its people with health care. Long overdue is the recognition that health insurance is a necessary social service that should be accessible to all citizens.”

  40. We buy my wife's expensive drug through a Canadian pharmacy that gets it shipped directly to us from India. Wake up Americans; there are ways of getting expensive drugs for a lower price if you look around.

  41. NYS has an excellent program for elderly called EPIC that picks up a lot of this cost. Application is a one page form, and worth checking out.

  42. Tell me, again, why medicare for all is a good idea?

  43. @Janet : It needs to be combined with a drug plan that can negotiate with drug companies.

  44. Thanks, Paula, for your article. I read this and my head almost exploded. That’s how complicated the formulas are. In the 2019 open enrollment period, I was frustrated by the difficulty of the new, “improved” MyMedicare site. It was anything but. And I’m not sure I picked the right plan for my husband this year, even with the broker’s help. She herself had trouble, because of the changes that ended up causing more confusion. For one thing, the site did not list brands of needles for injecting insulin. So I thought it was paid under Part B, grouped with devices, the way diabetes test strips and blood-drawing lancets are. Turns out, needles for injecting insulin are covered under D — so why couldn’t I include them in my husbands tailored list to then figure out which plan was cheapest overall this year? They were left off the site altogether when searching drugs alphabetically. Then factor in the different drug tiers, the cost-sharing formulas, the yearly deductible, the monthly premiums, the percentages — It’s ridiculous trying to figure it all out. Also, if one carrier offers several different plans with different costs around these features, they sound the same. It's maddening. And I begin to wonder if D plans are even worth the expense to begin with. And I wonder if this brain-exploding complexity is deliberate, so seniors will be deterred from doing their homework. The insurance companies win. I will tell you this: it’s cruel to seniors. We lose.

  45. Yes, Part D is important. It covers any IV antibiotics that many need to treat such things as pneumonia for 6 weeks under Homecare. I see many patients without a pharmacy plan and the costs are outrageous. But even with Part D there are still out of pocket costs not covered. It is maddening.

  46. @Amy I too found the "improved" MyMedicare especially frustrating. I called the local office and complained. But, ended up calling each of the companies I was considering to check on coverage of insulin needles and a couple of other items. Worse was trying to determine my share of a CPAP if I changed plans. No one could tell me exactly what would happen as the plans used different durable medical equipment providers. At best I would pay my share an additional year, at worst I would get a another new machine. It does not make sense. I entered the donut hole in October this year. Luckily my doctor gave me samples of my Tier 4 insulin which tided me over until January. But, he did not have samples of my Tier 4 COPD meds, so I skipped it for 3 months. This year I am projected to enter the donut hole in September, but it is also projected that I will not exit the donut hole.

  47. @Gwen All of this nonsense is unnecessarily complicated. Americans suffer as a result. Insurance companies are cash cows as are the Pharma.

  48. Ok gang let's go over it again what history has taught us. 1-Get a national, affordable, quality health plan like just about all of our peer countries have and some third world countries have also. 2-Never eliminate co payments or deductibles completely because if you do you make the system ripe for abuse from greedy medical pros to hypochondriac people who will demand any drug on the market.

  49. What amazes me in this is that I'm a healthy 49 year old with a Master's Degree and a strong grounding in mathematics. And I can't make sense of any of this. Just buying our own insurance on the state exchange -- and understanding how our policy works and what it covers -- is hard enough. Imagine that you only have a high school education. Or a serious illness. Chemo-brain or the onset of Alzheimer's. Imagine that you are the caregiver of terminally ill spouse, or parent or child. How do you possibly make sense of any of this? And if you aren't wealthy, how do you afford your medications?

  50. Don’t worry; I have a Ph.D and I don’t get it, either

  51. @Rose: I recently purchased health insurance on the state exchange and found the process maddening and unnecessarily hard to figure out. I thought about those who don't speak the language or are ill and imagined that they may not be buying what they think they are. It's sad and shouldn't be set up this way but unfortunately, it is.

  52. @Chris Sleight Me too. I could barely get through the labyrinth of this article and basically dont understand it. A shell game.

  53. Q: What is the difference between drug companies and a Mexican drug cartel? A: Drug cartel pricing is logical

  54. If a one year supply of Xarelto can be ordered from Israel for $698, there is no justifiable reason for it to cost more in the US. To claim otherwise is pure sophistry.

  55. Here's a concept. Negotiate low prices. Canada does. In our ophthalmology office we have seniors who use eyedrops to control their glaucoma. Drugs can lose their efficacy, forcing seniors to move to newer formulations, drugs without generics. The donut hole explains a lot about why patients suddenly cannot afford their drops, when they could the previous visit. Imagine if it were a drug that kept their heart beating, or prevented strokes. Imagine the cost of society paying for years in a nursing home because we don't want to figure out how to pay for prevention. We have our priorities skewed and make stupid decisions. Control the costs coming in, rather than the usage.

  56. @Cathy The newest efficacious drug for glaucoma is reportedly Rocklatan (no generic) approved by the FDA in the past year or so and and it is exceptionally expensive. More common drugs have ingredients like brimonadine and dorzolamide and benzyl chromium chloride which many cannot tolerate.

  57. There are only about 20,000,000 Medicare beneficiaries truly on Part D, the standalone prescription drug coverage portion of Medicare. Another about 20,000,000 people on an integrated public Part C Medicare health plan get their drug coverage -- almost always a feature of a Part C plan -- using the Part D mechanics but they are really on C, not D (that is, Part D terms and conditions do not affect their plan decisions). The other 20,000,000 get private coverage, typically through a group retirement plan tied to a former employer. Either way, most beneficiaries did not have the initial deductible described in this article. That was only a suggestion. Similarly the 25% co-pay described in this article is the guideline maximum; it is not true for most drugs and most people Of the 40,000,000 on C or D, about 15,000,000 are on Social Security Extra Help/LIS and are and never were affected by the donut hole. They get both their drugs and the plan itself basically for free. Another 10,000,000 or so are on Medicare-related state pharmaceutical assistance programs (not available in all states) and are and were only minimally affected by the donut hole. The remaining 15,000,000 mainly upper income Medicare beneficiaries could always buy a rider on top of their Part D to protect themselves against the donut hole. Bottom line: donut hole politics were always a crock brought to you by Hoadley and Neumann. Only a few percent of very rich people on Medicare were financially affected

  58. This is inaccurate. The drug coverage in every Medicare Advantage plan follows the template: four stages of coverage beginning with the deductible stage then the initial coverage level stage followed by the coverage gap and finally the catastrophic stage. Many Medicare Advantage plans have no drug deductible while others impose a deductible on drugs in tiers 3-5 only. They all have the same $6360 threshold for moving into the catastrophic level. The only safe approach is to use to find out which plan is going to cost you the least money for premium and copays combined EVERY YEAR. You can compare drug plans and advantage plans to see which is better for you. Often drug costs in Medicare Advantage plans are higher than in standalone drug plans.

  59. @D Which is what I said in the second sentence. But the point is that people who choose Part C (by far the most popular choice -- two to one -- of people just fully joining Medicare today) are not making that choice on Part D terms and conditions.

  60. @Dennis Byron you're putting in some hard work shilling for insurance companies. Good job!

  61. Unfortunately, Part D is when all the massive US brand drug price increases began. That is when the Health insurer/PBMs were given control of the program. Instead of working for us, the health insurer/PBMs began massively raising prices in partner with pharma. Our health insurer/PBMs have been getting secret “fees” from pharma tied to each and every price increase for more than a decade now and it gets worse every day. A simple, but secretive scheme. MS, insulin, arthritis and many other old brands now up 5-10-fold compared to Europe, when all were the same price when Part D began...please read/hear about my 7-year whistleblower efforts to stop it at a new website: Hope you will share. Thanks. John R. Borzilleri, M.D.

  62. Why does there have to be a hole. It makes no sense.

  63. I would appreciate knowing how Judge Lieberman orders Xarelto from Israel. Without it, my husband would be dead or incapacitated by a stroke,the result of a heart condition which his behavior did not cause. It’s a very expensive drug, and the doughnut hole hits us by September. We afford it but would prefer to spend those precious dollars on retirement fun.

  64. It's all a scam it always has been because our dirty rotten bribe taking politicians hate the American people and it is hate. There is no excuse for why and how Medicare and Medicaid is set up. Health plans with mine fields are just that.

  65. Two days ago, my daughter walked into our local pharmacy and was told that her prescription had a $2700 bill for which she would be responsible for $1135. She has a severe and chronic mental illness and is on disability and therefore is on both Medicare and Medicaid. Medicaid told me they wouldn't pay for her portion of the b ill--it usually follows behind and pays for those items that Medicare doesn't pick up--because "Medicare is supposed to pay for that." But my daughter's Medicare Part D plan would only pay a portion of the bill, citing deductibles. co-pays, and co-insurance. The insurance company was essentially in the position to decide what Medicare would and wouldn't pay, contravening Medicare coverage for their own benefit. Fortunately, her doc will get my daughter through this month with free samples she gets from the drug company and Feb 1, my daughter will have a new Medicare plan that covers her prescription. I spent hours on the phone with Medicare sorting thru drug plans with a cheerful and patient customer service rep. All I could think was what happens to an individual with a severe mental illness who can't navigate the system? Watching my daughter sob as she worried that she would no longer be able to afford the drug that stabilizes her I had my answer: they end up off their meds and on the street. This so the insurance companies can pad their pockets when states mandate "managed care" for Medicare and Medicaid. There has got to be a better way.

  66. @mystery dancer That is a horror story. The system is too horribly complicated for anyone who uses it, and worse for those who cannot cope or understand - categories which include many of the people using Part D. And it is worst of all for those who urgently need a particular medication and have no private means to purchase it.

  67. @mystery dancer Excellent post. I ordered from Canada medications for mental illness for my adult daughter. The medications in Canada were generics. U.S. drug companies would not allow the generic meds to be sold in U.S. At one-fourth of the cost, my daughter was able to maintain her sanity. The Canadian company rep said that most of their business was in Florida because seniors could not afford their medications. The Canadian rep was so understanding and compassionate. Previously, my daughter had been going every few days to an American pharmacy to buy a few pills at a time since she was broke. A pharmacist had mistakenly marked that the prescription had been "fully filled" on a previous visit. My daughter tried to explain that was not the case, but the pharmacy didn't care. I called Canada after she sobbed in the car that she was going to go "crazy" without meds. The U.S. medical system is heartlessly geared toward the industrial medical complex and rich people.

  68. "Part D premiums have remained stable (averaging about $30 a month) for years", how ever, the insurance companies with their playing games added or increased deductibles, shifted tier 2 and 3 drugs to tier 3 and 4, increased percentage copays, etc. etc.

  69. @Ellwood Nonnemacher When Medicare part D policies were first available in 2006, there were plans that had zero and $5/month premiums available. At the time, the average total monthly cost was around $20, the federal government chipped in 25% or $4 and the consumers paid an average of $16, which varied between $0 and $40. If someone did not sign up when first eligible, and they later signed up, they would be charged a 1% penalty of the average monthly premium per month of delay which would be applied in perpetuity. Someone eligible in 2006 who waited until 2016 to buy a policy would have to pay $36 per month plus the average $30 per month or $66. Retirees, even those who were not experiencing high drug costs, knew someone who was experienced high drug costs and signed up in higher than anticipated proportions, particularly since there were zero and $5 premiums available. Someone with low or no maintenance drug costs would sign up for a zero or $5 plan. The insurer would collect $4 or $9 per month and the person with no or low cost drugs would get a small reduction in their generic drug costs relative to what they would have been paying anyway.

  70. @ebmem See this is just so difficult to understand for normal people. The government is in collusion with the insurance companies.

  71. @Volley Goodman Because the insurance companies make sure to give plenty of money to politicians, so that a) the politicians are elected, b) the politicians do what the insurance companies seek. Not ideal for American citizens.

  72. Medicare prescription drug plans cover out-of-patent and inexpensive drugs that are affordable anyway, but universally the more expensive or newer drugs are in high "tiers" or not even on the formulary. What surgery is more common for Medicare recipients than cataract surgery? The eye drops prescribed before and after cataract surgery are not on the formulary for any Medicare D plan in Oakland County, Michigan. The pharmacist took pity on me and rather than charging me $200+ she found coupons to buy the drops without using my so-called insurance.

  73. @Bonnie Luternow If United Healthcare, which has 75 million covered, has not been able to negotiate a satisfactory price for the eye drops, what makes you believe that Medicare, with 60 million eligible for coverage but only 45 million who are electing to buy coverage, is going to be able to negotiate a lower price? It will be similar to Medicaid and VA drug formularies: it will not be a covered drug. And why would it be that the price to the uninsured, eligible for coupons, would be lower than the co-pay or the drug is unavailable to those insured.

  74. @Bonnie Luternow I was shocked to see that PrEP is in a high tier. How many people will contract HIV because a medication that we should be prescribing as widely as possible is unaffordable?

  75. @Josh Hill Even without the donut at 25% copay for a drug regimen that costs $54,000 a year if you have HIV you better be rich or have some other cash source to pay for it. Most HIV drugs are in the highest tier. BTW why would the drug companies find a cure to HIV disease? Anyone in business is there to make a profit. When you make $54,000 a year off HIV drugs per patient - same drugs in South America and Africa cost around $1,400 or less a year per patient there is no incentive to find a cure. That's capitalism.

  76. Please do a bit more research about choices for drugs. I have exactly one insurance choice for my prescriptions. I live in a rural area and need a drug I have been taking for over 25 years. It’s expensive and there is no generic equivalent. When I search for options for coverage, there is only ONE option.

  77. Without drug price negotiation by CMS, anyone on Medicare who starts a costly drug can expect to pay ever higher out of pocket costs, despite Part D, the donut hole (or not), etc. The initial structure of Part D was created chiefly by drug company lobbyists, and half of our legislators (GOP) sat out the proceedings on Obamacare and Part D, assuming it would never be enacted--so not enough perspectives were considered. Other readers commenting here, cite various ways beneficiaries either pay extra to avoid falling into "the hole", or may qualify for additional help. This does nothing to change the multiplying of prices for drugs, PBM's playing footsie with pharma, and ultimately taxpayers paying far too much, one way or another. The only real solution is drug price negotiation.

  78. Crohns drug Pentasa costs $90 from Canada Pharmacy delivered to your door. It costs over $5000 at your local CVS, but “only” costs $100 as a Tier 4 drug via Medicare (with taxpayers kicking in the $4900 difference). Why doesn’t Uncle Sam buy our meds from Canada? Why doesn’t manufacturer Searle allow generic Pentasa to be sold in the US? If you answered “Greed over need” to either question, give yourself a little treat.

  79. I'm about to go on medicare myself soon. The way trump has been trying to gut health insurance I expect the coverage to worsen in the near future. This GOP doesn't care for anybody who has medicare, social security, or any other type of "entitlement" as the republicans call it. They don't want you going to Mexico or Canada for your drugs, they would much rather you buy prescriptions at full cost than cut into their political contributions from the drug makers. Although you've worked your whole life they prefer to give you squat...

  80. Q: Which congresspersons are not owned by drug lobbyist? (trick question, there are none)

  81. I can't think of a more loathsome legitimate business in the U.S. than pharmaceuticals and their anemic excuses for keeping their prices for some drugs higher than anywhere else in the world. They do it because the politicians they contribute to allow them to.

  82. It's a shame Joe public doesn't have enough money to pay their representatives as much as the drug companies do.

  83. The Bush administration developed Medicare Part D, and pressured on Congress to approve it. As you'd expect, it puts Republican constituents and interests ahead of patients. Reliance on private insurance companies and prohibiting the government from negotiating drug prices serves the Koch/Libertarian dream of privatizing Medicare. (Bush had proposed wholesale replacement of Medicare with vouchers, but faced too much opposition. Along with "Medicare Advantage," Part D was an incremental step toward privatization.) These features also provided generous return on the campaign investments of the insurance and pharmaceutical industries. The "doughnut hole" served deficit hawks who throw tantrums whenever Democrats propose a program to benefit non-wealthy Americans. (But they had no problem with Republicans borrowing $1.5 trillion for a tax cut that funded corporate stock buybacks and gave wealthy donors excellent return on investment.) Our "American exceptionalist" health care system is a cancer on the body politic. Its executives and shareholders grow richer as the rest of us get sicker and poorer. Obama had a chance to treat the cancer, but he chose to just put some bandaids on it. They patched a few of the most egregious symptoms (and added complexity to an already complex system), but otherwise allowed the cancer of greed to continue its destruction. Yet Republicans seek only to rip off the bandaids out of partisan spite. One more reason to vote in November.

  84. Is the long-term plan to keep us confused? Part D, Part F, Part G are all used... Lower drug prices, You've put some in crisis, Listen up, Congress... we're not amused! Both parties bear responsibility for this mess.

  85. Understanding the donut hole is so confusing. Proust is easier to understand.

  86. As a multiple myeloma patient, anybody saying the doughnut hole has closed is misrepresenting the facts. MM drugs out of pocket costs are in the tens of thousands of dollars per year range. The hole didn't close. They simply changed the name to protect the thieves.

  87. There is a straightforward market approach that Congress could enact. All pharmaceutical transactions must include a most favored nations pricing provision at the wholesale level. Drugs could not be sold to the U.S. marketplace for more than the Canadian or Israeli marketplace.

  88. This is a perfect example of an expensive complicated and bureaucratic mess for a government run monopoly. To my liberal friends. do you really want a massive mandatory one size fits all government bureaucracy taking "care" of you? This wouldn't be tolerated by a private insurer that wants to stay in business.

  89. @obummer Actually, I'd argue that this is the perfect example of what happens when a so-called "health system" is designed around the prerogatives of PRIVATE medical insurers (and in fact many laws have been written by health industry lobbyists). The ACA was very messy and resulted in some unpredicted increases because maintaining the private insurance industry was made central to planning. Its not that it would be easy to design a easily workable and funded system, but that such an effort has not been allowed to come to the fore because of the industry's strength and pressures on lawmakers. It also faces pushback from those who want to cap costs, but refuse to consider the fact that doing that does mean having to make decisions about medical priorities. SO we continue with the Wild West approach.

  90. @obummer Medicare is shockingly complicated, with the various parts ranging from A through N, each with its own premiums. Eligibility for many parts depends on the year you start paying for Part B coverage. The various parts are the result of ongoing congressional tinkering with the Medicare system because of rising costs re to increasing overall participation (baby boomers). It is indeed an expensive and complicated bureaucratic mess. And anyone who thinks they don't need Part D coverage because they're not on any meds...well, buy it anyway. Because when you do need coverage and only then buy a Part D plan, you will pay a permanent monthly fine on top of your premium for all the months you were eligible but did not enroll (unless you had creditable coverage for those months from an employer plan). I'm going to stop here with all the caveats because it would take forever to list the details of this giant mess.

  91. @Ann And there are little traps all over the place when signing up for Medicare. Each part has a different 'eligibility' window, I thought that the 'window' for Part D was the same as for Part B but when I went to sign up for Part D apparently the window had already closed (although still open for Part B). It takes a lot of attention to the fine print ! And all of it costs money. If you're still working and not drawing Social Security yet, it's very important to make sure you are paying your 'premium' (although it's not called a premium) or you will lose coverage and be fined for the Rest of Your Life when re-enrolling. (If on SS, the payments are taken out of your SS before you get your share).

  92. Americans would rather die - or allow their neighbors to die - than regulate drug manufacturer and insurance company profits, because that's "socialized medicine." No wonder our life-expectancy is two years lower than the UK and almost four years lower than Canada.

  93. I see no mention of extra help available to lower income SS beneficiaries, this can lower your costs to 3.60 and 8.95 until you get to catastrophic coverage where you pay nothing.

  94. Capitalism cures cancer- but not for everyone. What we are doing produces about 25,000 deaths a year while producing gigantic profits for companies and their CEOs. They have a vested interest in making sure we NEVER figure out that this system works for them- not us. They have been warned that change will be catastrophic for THEIR standard of living so they "guide" the political process to protect themselves. How can this be measured scientifically? If Bernie Sanders is receiving a high number of individual contributions and is crossing the financial threshold of a viable candidate how big of an increase in social media bashing occurs? Is there a direct correlation? As a back up measure the same index can be used for Warren. If we change the system will the GDP go up or down as that money stays in the bottom third of the economy? Let's find out.

  95. This year, my Humana Medicare Part D plan more doubled from $28/month to $58 / month. ...far from the Part D number quoted in this article. I guess next year it will $116 / month. Only healthcare can raise prices 100% per year

  96. @B Warne That was the price of closing the donut hole.

  97. All the games and gimmicks would be unnecessary if we didn't spend recklessly on absurdities: military pork, tax cuts for the wealthy, farm subsidies for profitable corporations......add your own obscenity.

  98. Doughnut Hole? Let them eat cake!

  99. The United States is a wonderful place to live.... mostly.... sorta.... maybe not

  100. Americans have this idea they’re the greatest country in the world. You think other world citizens from varying countries are chanting “we’re number two”? Look at the cost and inaccessibility to quality heathcare, the so called justice system, rankings in education, maternity leave and infant mortality rates to name a few. You’re not number one, you’re not the greatest and you won’t be until multiple institutions, especially healthcare is sorted out.

  101. Confusing people while robbing them blind is an old and cherished trick of criminals. Now that a large proportion of our Government is criminals, they see no reason why the old ways can't be applied to gain 21st-Century profits from all those relatively rich old people. Yeeee-haaaa! It's the roundup, boys!

  102. @Pete Rogan Drain the swamp. Not only Medicare participants get caught in the gaming of insurance companies and pharmacy benefit managers. Frequently the price for an uninsured patient is lower than the co-pay for someone insured. With Plan B policies, the catch is you don't get credit toward your deductible or donut hole if you don't go through your insurance. It would be an excellent legislative change if people with insurance could get credit for buying drugs that are cheaper than co-pays, but that would cut into the profit for the big boys who paid Obama to rig the rules..

  103. Sorry, my friend. Ever been uninsured and tried to pay cash? You pay a LOT more. For office visits, hospitalizations, for prescriptions. That’s because you don’t benefit from the insurance company’s ability to negotiate a lower rate with the provider. The actual cost as charged is much higher to a cash carrying customer. Counter-intuitive but true. And nothing to do with Obama. It’s always been that way.

  104. Oddly, for my two inexpensive generic prescriptions the cost is less if I pay out of pocket than if I pay the price through part D. So the part D insurance is jacking up the price.

  105. My hat is off to Mr. Lieberman for doing what Republicans tell us to: shop around. Keep shopping, Mr. Lieberman, for different insurance companies make Xarelto available at widely different prices. My husband takes Xarelto and found that the prices varied from $28 to $450 per month depending on the plan. Since that's about the only drug we buy, right now that determines which plan we choose. Of course, these widely varying prices are simply nuts. Consumers should not have to use a weed-whacker to navigate the system.

  106. It was mentioned in the article about cancer drugs. I take Revlimid which under my plan costs about $14000 plus a month for 21 pills. Because it is a pill it is covered under Part D. If it was an injection or could be an injection it would be under Part B (much cheaper for me). As a result and because I don't qualify for any of the grants I will pay about $11000 this year for this life saving drug. The first month is the toughest because you have to get into the catastrophic coverage. So about $3000 for the first month each year and then roughly $700 a month thereafter. The drug works very well for me and keeps my multiple myeloma in check. My frustration is that I have worked very hard all my life only to be hit with this very expensive cost to stay alive.

  107. @Emily Brown That's quite a donut hold there.

  108. @Emily Brown Injections that have to be administered in a doctor's office have a 20% co-pay with no out of pocket maximum. If this is a drug that you have to use indefinitely, your co-pay for the year would be $33,600, plus an office visit cost for each injection. You should have shopped around last year for a better part D plan. The co-pay varied from $4,607 to $18,427 according to Good Rx.

  109. @ebmem Why should anyone have to "shop around?" The drug is the drug and any plan should cover it. Same for an injection.

  110. Why are drugs so expensive in the US? The answer is marketing cost. Alan Sager of BU has found that the marketing costs of Big Pharma eat up about a third of their budget and are about 3 times what they spend on R &D. So what are these costs? Well, first of all, there are the irritating ads that saturate the air waves and the print media. The first one was on May 19, 1983. The only other country that allows prescription drug ads is New Zealand. A simple act of Congress or a regulation by the FDA could eliminate them. Then there are the pushers that infest doctors' offices. These are totally unqualified salesmen whose main purpose seems to be to get doctors to use drugs in unapproved procedures. Finally, of course, there are the payments to physician, both under and over the table. These range from free lunches, to paid vacations at expensive resorts under the cover of a lecture or two so they can call it a conference, to huge contracts as consultants. The purpose of the ads is to get us to ask for drugs our doctors do not think we need while the pushers and the payments are to get physicians to prescribe new expensive drugs even when older cheaper drugs do as well if not better. It has been conservatively estimated that if this marketing is eliminated, it would lower the cost of health care by $100 Billion each and every year.

  111. The bill that established Part D should have been titled The "Welfare for Big Pharma Act."

  112. @ Len Charlap So right you are. The bill for Plan D was deeply flawed at the outset, and was structured to benefit profits for Big Pharma and the private insurance industry at the expense of American retirees.

  113. I am in favor of private companies in situations where there is an open market, where there is no restraint of trade, where there is competition and where it makes sense (see below). In cases where this does not exist, then and only then should the government step in. For example, in colonial Philadelphia, there was no fire department. Each fire insurance company had its own private fire department. When you bought insurance, you got a medallion to put on your house. If a fire truck from the Green Tree company came to a burning house that had a Penn Mutual medallion, they would let it burn to the ground. After this happened a few times, a municipal fire department was established, a government fire department Other examples are police, national defense, roads and bridges, etc. The data today overwhelmingly show that health insurance is one of these markets. This article points to the idea that drug manufacture is also. If you are concerned with innovation, consider this. For most drugs, the research that discovered them was paid for by the government, either directly or through universities. For example, statins were discovered by 3 Japanese academics. So if drug research, development and manufacturer were done by the government, innovation would not suffer. It might even pick up since the motive would be to help people rather than to make a profit.

  114. @Len Charlap After the drugs were invented and patented, drug manufacturers spent billions for toxicity tests, efficacy tests to get approval from the FDA to market the drugs. At that point, there were three years left on the patent life.

  115. @ebmem - I don't know what drugs you are talking about (statins?), but the bottom line is that even after spending a third of their budget on marketing (3 times as much as they spend on R&D), the drug cos average 20% profit which is double the profit of all US industries.

  116. As a very recent example of why medical drugs should be a government function is the article published om 1/17 with the headlines: "W.H.O. Warns That Pipeline for New Antibiotics Is Running Dry In two new reports, the global health agency says only government intervention can fix the broken market for new antimicrobial drugs."

  117. Pharmacist here - we have seen copays around $400 for the first fills this year of higher cost meds- patients were not expecting this and many are deciding to forego their treatments until they reach the deductible. How this is better, is beyond me.

  118. I have had bad reactions to several generics, or they didn’t work, so now I take brand only, at a significant additional cost. But what good are cheap statins or blood pressure dugs that I can’t take or which don’t work? The problem lies with Congress, for not funding the FDA to inspect every manufacturer - unannounced - especially those in India and China, where the bulk are made - every year or two, and with the FDA for not being far tougher when problems are found. There are terrifying books and articles which explain just how dangerous our virtually unregulated generics are. The ACA made them the backbone of our healthcare system but subsequent events have revealed the problems in that strategy. For now I can afford this - I take only 3 meds - but who knows what the future will bring?

  119. I wish more Americans could experience healthcare in a Scandinavian country and realize what a complete mess we have here. It will only change when we all demand change.

  120. This article is as clear as mud. I wonder if the author read what he/she wrote will he/she understand what is written.

  121. If we are lucky, we will all live long enough to qualify for Medicare. My question - Big Pharma and Congress are asking a group of people, some of whom are arguably in the twilight of their cognitive years, to negotiate a system that unnecessarily complex. Forget Medicare for all - can we start with a rational drug policy that doesn't require a spreadsheet annually to figure out which Part D plan or Medicare Advantage plan makes the most sense? Even trying to seek out help is a baffling array of websites, books and counselors. The only people who aren't impacted - those people who are wealthy enough not to worry about the cost of medications and retired members of Congress.

  122. @Rkolog I’m with you except for your Medicare Advantage suggestion. MA, if not outright evil, is part of the problem as it is essentially signing over one’s Medicare benefits to a private, for-profit company. And we all know how well that’s serving our needs.

  123. We pay an additional $8,000 a year even through we have Part D. Why? There is no generic asthma or insulin. Both asthma and diabetes are fairly common so it makes me wonder how many other people have the same problem?

  124. Halfway through this article, my eyes glazed over. It's not the journalist's fault; it's the fault of needless complexity of our profit-driven health insurance system that even Medicare must genuflect to. Congress has still not remedied the most egregious features of Part D: that Medicare cannot negotiate prices with the drug companies. Senator Bernie Sanders & Congressman Ro Khanna have introduced bills to correct this, but even if they pass the House, they will die in McConnell's graveyard for bills and Trump will never sign them. Sanders' Medicare For All would simplify the whole procedure, capping annual drug costs at $200 per beneficiary. After 4 years, everyone would be covered by Medicare. Simple and less costly than our current system. And paid for by a 4% income tax, with the first $29,000 of income exempted, for full health, drug, vision, dental, hearing and long term care coverage.

  125. Why can't we use our Medicare or VA insurance overseas? If I need a procedure, it would be far less expensive in many other countries. Prescriptions would be 1/10th. Why not grant us Americans permission to save Medicare and VA a lot of money ? Medicare or VA should follow us wherever we go. Instead, if we want coverage over seas, we have to purchase insurance.

  126. I think the most expensive things I buy on a per ounce basis are Xarelto pills. And they make them so small that you cannot buy a larger dose and split the pills. Nothing like a simple, understandable pricing system. If there were a quiz on how this all works, about the only people who might pass are pharmacists.

  127. We are at the mercy of Big Pharma, Insurance companies and our Politicians. Not much hope it will get any better unless the new President in 2020 has a solid plan to stop the madness

  128. @Jean So, first, let’s get a new President. Second, let’s flip the Senate and maintain the House.

  129. @PJ I fully agree

  130. Worth noting the UK’s NHS offers free drugs to everyone under 16 or over 60. People in between those ages pay a flat fee of approximately $12 regardless of the actual cost of the drugs. This is the standard we should be aspiring to.

  131. I completely agree. It’s a shame how our political system works to the greatest advantage of amassing wealth for those already wealthy beyond imagination. If it were not for a foundation giving me my much needed meds, I’d be disabled.

  132. That’s way too progressive for U.S. voters. Pity.

  133. It is nothing less than obscene that there is no cap on catastrophic drug costs. The fact that some elderly people dying because they can't afford medication is reprehensible. As someone who just turned 65 and currently has the best Part D plan he could find (I did compare), I've found that the program has other shortcomings as well. For example, a medication that could benefit me would cost me thousands of dollars a year because the insurance companies in my state have put it in a high tier -- this despite that fact that there's no alternative. (In other states, it costs virtually nothing.) And of course Congress decided to protect us from the heartbreak of lower drug costs by preventing us from buying drugs in Canada . . .

  134. @Josh Hill Let me fix your second sentence: The fact that some people are dying because they can't afford medication is reprehensible. Other than that, I agree with you.

  135. @Josh Hill Would you mind saying which plan you chose? Thanks.

  136. I find many of the comments on this article bizarre. Big Pharma and Corporate Greed are international, but Americans are the only ones paying these prices. Think on it.

  137. Every year our insurance agent plugs my husband's and my drugs into a computer program that lists the costs each insurance company charges for the drugs and our monthly drug costs with each insurance company. Sometimes my husband has to contact his Dr. to change medications as the current insurer might discontinue coverage for a medication he is taking. The cost of meds varies greatly amount insurance companies. The government's system is aggravating but manageable. What is obscene are the drug manufacturers who artificially raise the costs of medicine such as insulin. The companies also make slight changes to medicine formulas enabling them to renew the patent meaning that no generic drugs can be made and the company can continue its high price.

  138. I take expensive meds including 2 types of insulin. I used to get into the donut hole early in the year(February) if i had to get insulin and pay the high copays in January. I would then have a few months to get out of it and into Catastrophic coverage. I actually was happy to be in that range as my drug costs dropped substantially for the remaining months (usually at least 6 months). Now it appears i will pay more, and not enjoy the months of lower costs that i did. I saved my whole life for retirement and as my luck has dealt me the drug companies will reap what i saved. Something MUST be done to stop this thievery.

  139. As far as I am concerned they just renamed the donut hole the the “gap”. I went through a broker and we could find no plan this year that covered my diabetes meds for under 500 a month. My plan refused a tier exception, Canada does not sell it and I am too “wealthy “ to get any assistance. I am unable to take any other type of Med due to a metabolism issue. The other drugs in this class are even more expensive since they are newer on the market. Last year I went into the donut hole in feb and was unable to afford it the remainder of the year. I work with a medication management therapist aka pharmacist and she decided I should just “wing” it this year. While the pharmaceutical companies are raking in their profits, so too are the retail pharmacies who add on to our drug costs by charging some mysterious fees that, in my case bumped up the costs of my drug by hundreds per month. What I don’t understand is why us retired folks or those on disability are expected to bear the brunt of pharmaceutical company costs x we have the most need and least ability to pay. Like squeezing blood out of a turnip...

  140. Go see the free unbiased (not a broker) Medicare volunteer at your local senior center or like facility. Are you saying the drug was not covered by any plan? Or do you mean it was covered but was going to cost you $6000 out of your pocket per year. Or do you just mean it is very expensive medicine ($6000 a year out of pocket under Part D on average would on average get you over $100,000 worth of medicine)

  141. This is insane.

  142. I have two prescriptions for common inexpensive generics. The prices through part D are actually higher than just paying out of pocket, which I do. The cheapest part D policy is what I keep to avoid future penalties. My third prescription is only covered by the most expensive part D policy. Paying for this would equal paying the US price for the drug. So I get it from Canada at one quarter the US price. Something is very strange here.

  143. Will the pharmaceutical companies ever declare they have "enough"? They fight limitations on costs tooth and nail. They resist all attempts as negotiations. They hunger, lust for more and more money every day, every year of our lives. And it is never, ever, enough. Ever. 10 years from now this article will be re-written with higher numbers and deeper resignation, and not one thing will be different except the death rate of Americans.

  144. Not to mention the insurance companies doubled their Part D premiums this year.....

  145. Every time I read articles like this I remember Barack Obama’s heartbreaking description of the hours his mother, who was dying of ovarian cancer, had to spend arguing with her insurance providers about her coverage. Ten years ago, while I was being treated for breast cancer here in “socialized medicine” country, I never had to spend any time worrying about the affordability of my coverage or trying to decipher incomprehensible bills, but was able to concentrate on my family and friends, and getting better. And for the five years following my treatment, whenever I went to the pharmacy for medicine, my name popped up on the pharmacist’s computer to say that any medicine connected to my illness was covered 100%. This is how it should be in any civilized society.

  146. @Susan Of course, if you are regular NY Times reader, you know Obama's story was a lie. The coverage his mother was arguing about with an insurer was disability insurance that she had let lapse... it had nothing to do with health care. It's a shame that people outside of the United States believe all the propaganda leftists spew about the United States (but that's the job of leftist propagandists, n'est-ce pas?)

  147. Healthcare in this country is so screwed up we should be ashamed of ourselves.

  148. Thank you Paula for explaining a very complex topic. As I help guide my mom with her Medicare expenses, and as my husband and I live through our last few pre-Medicare years, this is of intense interest. After years on traditional medical insurance, we know exactly how much we need to set aside to make sure we can buy our medications. Even if our medication changes over the course of the year, we know that the maximum out of pocket amount will be the most we will pay. Clearly, we can’t count on doing the same on Part D. It is clear this problem existed before the Affordable Care Act, so even if the Act is gutted, the issues you describe need addressing.

  149. @Susanne Gilliam Luckily, because you live in Massachusetts, you will get the protection you are used to through a program called Prescription Advantage which sits on top of Part D. It is available to all but the top 10% of Massachusetts Medicare beneficiaries as measured by income. There is no asset test. (So hold down your income and maximize your assets, which is good advice for everyone in retirement, having nothing to do with Medicare -- e.g., to lower the tax you pay on your Social Security benefits, the ones you earned by paying the Social Security tax for 50 years)

  150. There are numerous private drug discount plans like GoodRx and WellRx available to the general public. Unfortunately, if you are even eligible for Medicare these plans will not cover you. Not sure why this is, but Medicare rules do forbid manufacturer's discounts to Medicare beneficiaries. Whatever the reason, people eligible for Medicare must either pay exorbitant, monopoly money pharmaceutical list prices, or must pay premiums to a part D insurance company. Others have noted that these plans offer deep discounts on already cheap preferred generics, but still charge high prices for newer, brand name, and non-formulary generic medicines.

  151. The cost of a generic drug I take went from a few dollars to $68 overnight. I dare someone to explain that to me. Capitalism at its best, I suppose.

  152. Medicare, Medicaid and Obamacare are scandalously partisan and effectively fraudulent. When it comes to drug coverage, upscale Democrats are well taken care of as are poor Democrats who get Medicaid coverage during their senior years. The rest, who are majority Republican, have to deal with the Medicare donut hole. Even more flagrant, the 30 million that Obamacare conceded would not be insured by the ACA are overwhelmingly working class Republicans. Democrats never speak of them. But they go on and on about the 2 million left uninsured by Republican states that have not expanded Medicaid. Democrats champion public health care that benefits the poor and badly serves the working class. And they wonder why the working class votes Republican. Totally oblivious seemingly devious and as partisan as McConnell.

  153. Please elaborate further and cite any Republican proposals for equatable healthcare after 2020.

  154. The US health care system is astonishingly stupid and malicious. Donut holes, co-pays, deductibles, Parts A, B, C, D, countless private Medicare plans to figure out, constant changes in coverage, costs that amount to a sizable percentage of retired people's income, enrollment periods, special enrollment periods, penalties for enrolling late (being penalized for *not* using the benefit), impenetrable websites, etc etc. The tax funded bureaucracy of creating and maintaining this morass is *very* expensive. Many people over 65 just can't cope with the maze and make decisions blind. It is daunting, frightening and probably intended to limit participation. Turning 65, as I just have (I'm a US citizen), is to enter a parallel universe of a health insurance snake pit. You know what you do here when you turn 65? Nothing.

  155. The best way to describe drug pricing in the US is arbitrary and capricious. I am on two very expensive drugs and a couple of non-formulary ones. I have found that the prices quoted on are often better than what I get through my otherwise pretty good AARP/UHC Part D supplement. Further, if I use the goodrx coupon instead of Part D, it does not count toward the donut hole. The downside, in addition to doing all the comparative math homework (a working knowledge of Excel is a plus), is that my prescriptions are now spread out over four different pharmacies in addition to the mail order part of AARP. It is a royal pain, but has saved me thousands of dollars. I would welcome a Presidential candidate who supported allowing us to import drugs from overseas. Then we could see how the free market works for the consumer for a change.

  156. So how do we combat antibiotic resistant superbugs when no one on Part D will be able to afford the cocktails of antibiotics used to fight these superbugs. It looks like most seniors will spend their entire SS check on drugs. Please vote Blue in 2020 to stop this madness.

  157. I wish this were a little more confusing.

  158. Of course there is still a doughnut hole and the cost of tier 3 drugs has increased. I take mostly non-generics, not out of choice, and I will enter that hole and it will now take $6,000+ to dig myself out of it. Even with catastrophic coverage, my drugs costs will run me well over that amount per year. So, please, don’t sell me the fantasy that the hole has closed. It’s very much alive and well and eats into my retirement savings.

  159. @Pups No that is not how Part D works. It will take you about $2000-$2500 out of your pocket to "dig yourself" out of the initial spend phase through the coverage gap, the donut hole, (should you unfortunately be among the less than about 10% of us on Medicare who is both so ill that you need over $10,000 worth of self-administered medicine and so rich you do not qualify for very generous financial assistance) to -- I hope not -- the catastrophic phase. The template co-pay in both phases is 25% but usually much lower in the IEP. In the initial spend phase, you would spend no more than about $1200 out of pocket (OOP) to buy about $4000 worth of drugs (at retail) depending on how inexpensive or "bad" a Part D plan you had (the higher the premiums the better the plan... just like everything else in life). 90% of us fall well below this upper bound. I am sorry you do not. In the coverage gap, you would spend about another $1000-$1500 depending on the plan for which you would receive another $6000 or more of drugs at retail. The reason is that the manufacturer discount you receive in the donut hole counts against your OOP even though it does not come out of your pocket Only if you enter the catastrophic phase, meaning you are very ill, would you be spending $6000 OOP. The typical co-pay is about 5% so you would be getting about or more than $60,000 in self administered medicine for that $6000 factoring in the OOP at the lower spend phases

  160. The article fails to mention Extra Help, the Medicare Part D low income supplement. In 2019 about 29% of those with Medicare Part D received Extra Help. For those with Extra Help, in 2020, the copay for any covered generic drug is $3.60 and the copay for all other covered drugs is $8.95. There is no coverage gap for the individual. For those who would be in the gap, the insurer pays nothing and Extra Help picks up that part of the cost. For example, for the COPD drug Anoro Ellipta, in 2019 a private insurer's plan paid $1,133.60 with the patient paying an $8.50 copay and Extra Help paying $126.50 until the "doughnut hole" was reached. The money paid by Extra Help counts toward "out-of-pocket" cost. Once in the "hole" plan then paid nothing, with Extra Help paying $1,260.10. Extra Help also pays all or part of the Medicare Part D premium.

  161. Yes, a step in the right direction, however, it does not go far enough. Look at the required deductible: "This year, after meeting the $435 deductible, you generally pay a flat price for each covered drug during the so-called initial coverage period. Different plans assign drugs to different tiers for which you pay specified amounts." This is an utter abomination, as they (insurance companies), want you to first satisfy the deductible before you get a price-break. I can attest to that from a very recent (2020) experience. This is why Bernie Sanders is 100% right when he says that Medicare should be able to negotiate drug prices and also eliminate the middle-men (insurance companies) who incidentally are skimming off the top and costing people billions of dollars. When will Americans (especially the retirees who incidentally keep on voting against their own interests) wake up and see how the rest of the advanced countries have dealt with these issues and demand the same from their politicians? I am compelled to make another pitch for Bernie Sanders' Single-Payer-Medicare-For-All.

  162. @George M. 1. Most plans have no deductible. Almost all the rest have a deductible well under the maximum. 2. It's not a price break. It's a co-pay. We Americans do not believe in gimme gimme gimme 3. Those of us who thought about such things back in 2000 when Clinton proposed Part D did not want the people who "negotiated" $1200 toilet seats negotiating our drug prices. So we left it to people like CVS who buy a lot of medicine. 4. The profit margin for insurance companies in terms of their Medicare activity is under 4%. Because of that low margin, increasingly insurance companies are leaving the Medicare business... being replaced by non profit integrated health delivery systems 5. Recent retirees are choosing these non-profit-sponsored plans over insurance companies two to one when they fully sign up for Medicare today (and saving $2500 a year over the Bernie Sanders approach and getting better health care) so I guess we retirees are not as stupid as you socialists think we are

  163. It is unclear to me if the pronoun “they” refers to patients only, patients and insurance companies combined, or insurance companies only.