Community Pharmacy and the Donut Hole

The other day one of our patients of many years was picking up a prescription.  "$599", she exclaimed at the pharmacy counter.  "I didn't pay that much last time", she continued.  After a short bit of pharmacy computer forensics, we concluded that all year long she had been paying $90 for a two month supply, last time she picked the prescription up she had paid $197 and yes, this time the total was in fact $599. 

The historical review of the computer records disclosed to us that our young lady had in fact moved 100% into the Medicare D coverage gap, sometimes referred to as the donut hole.  The previous prescription for $197 was her partial entrance into the coverage gap, and this prescription was 100% attributable to crossing part of the broad stretch of the donut hole.

So now what do we do?  During this time of year, late summer too early fall, we come across this particular situation quite often.  Seniors have been paying their co-payments all year long and then all of a sudden they enter into the Medicare D coverage gap.  This is the portion of the Medicare D program where they are responsible for the majority of the cost of their medications.  Over the next few years the coverage gap is being faded out; however, for now, it is still a significant "chunk of change" for quite a few people.

I have come to realize that most seniors do not think about or plan for the coverage gap.  When they show up at the pharmacy and see that their prescription is five times what they paid last time, they are always very surprised and need an explanation of what is going on.  At this point, we take the time to explain the Medicare D coverage gap process.  There is always an "Oh, now I remember" moment in the discussion where the customer remembers the "donut hole" and we proceed to work through the transaction.

With this particular transaction, our young lady was very pleasant; however, the cost of $599 was definitely throwing up a road block.  She was very well aware of the importance of this particular anti-arrhythmic medication.  She understands her care and is quite knowledgeable about how important it is to continue therapy without missing any doses.  We decided to re-process the prescription for only one month, rather than two and then take it from there.

Well, one month of the medication processed out to $300, and this was still a bit ominous for the young lady after she began to think that she would need to do this for two more months, at which point the Medicare D program will reset and start over at the first of the year. 

After a bit more consultation, we discussed the option of contacting the physician about changing from the sustained release form of this medication to the immediate release form.  She explained that the physician had discussed this with her in the past; however, she stated it had been much more convenient for her taking a pill twice daily rather than needing to fit a dose in every 8 hours.  It is interesting that with this particular medication, the sustained release form of the medication costs upwards of 10 times more than the immediate release form.   She agreed that, for the difference in cost, she would be more than happy to adjust her schedule to accommodate an every 8 hour dosing regimen.

Being after five on a Friday afternoon, the physician was not available for immediate consultation, so I explained the situation in writing and sent a fax off to the physician.  The customer agreed she would call the physician Monday morning and discuss the situation with him also.  If the physician agrees and authorizes an order, we will process a prescription for her next week for the immediate release form of the medication.   We then reprocessed the current prescription for seven days of the medication which came to an acceptable $70.

At this point, with three or four pharmacy customers standing behind her at the counter, she exclaims, "I'd like to see someone try and go through this process down at XYZ Big Box Pharmacy, this is why I come to My Community Pharmacy".   Immediately after, the customer standing next to her stated, "These guys are great, I love this pharmacy".   

Yes, working in community pharmacy definitely has its challenges; however, it is moments like these that help make it all worthwhile!


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