Home / Letter From The Editor / Oct. 27, 2018

Oct. 27, 2018

Oct 27, 2018

This week we have some great information on new ADA and EASD guidelines for treating type 2 diabetes. The focus is once again on individualized treatment and increased usage of newer medications. This goes along with a study published in Lancet Diabetes Endocrinology for using medications to prevent diabetes. All of these ideas mean that it will likely cost more in the future to treat our patients. This has led to a cry by our political leaders to rein in drug costs and make pricing more transparent.

One of the things that will likely be of benefit to our Medicare eligible patients — and was included in President Trump’s budget bill signed earlier this year — is the closing of the donut hole a year earlier, by requiring pharma to pay a bigger share (10% more) of patient’s drug costs.

Part D enrollees will receive a 75% Donut Hole discount on the total cost of their brand-name drugs purchased while in the Donut Hole. The discount includes a 70% discount paid by the brand-name drug manufacturer and a 5% discount paid by your Medicare Part D plan. The 70% paid by the drug manufacturer, combined with the 25% they pay, count toward your TrOOP or Donut Hole exit point. (This was to have been only 60% paid by manufacturer prior to change.)

For example: If you reach the Donut Hole and purchase a brand-name medication with a retail cost of $100, you will pay $25 for the medication, and receive $95 credit toward meeting your 2019 total out-of-pocket spending limit.

Medicare Part D beneficiaries who reach the Donut Hole will also pay a maximum of 37% co-pay on generic drugs purchased while in the Coverage Gap (receiving a 63% discount).  For example: If you reach the 2019 Donut Hole, and your generic medication has a retail cost of $100, you will pay $37. The $37 that you spend will count toward your TrOOP or Donut Hole exit point.

CMS has indicated that this will help many patients get through the donut hole with approximately 30% less out of pocket costs. Please be reminded that once a patient moves through the donut hole into catastrophic coverage their copay on all brand medications is only $6.60 per prescription.



We can make a difference!


Dave Joffe