Falling Into the Gap: How Medicare Part D Fails People with Rheumatoid Arthritis

Two months after becoming a Medicare Part D recipient, the cost of my monthly prescriptions jumped from $70 to over $1500. The culprit of my dizzying descent into the “doughnut hole” was the one medication capable of controlling my Rheumatoid Arthritis: the biologic Enbrel, which rings in at approximately $1500 per month. Without any other cheaper medicinal option, I was forced to pay the $1500. I am not alone: every person who requires expensive medications to function or to survive and only has prescription coverage through Medicare’s Part D faces the same financial trauma every year; either we pay for our expensive medications out of pocket for several months, or we are forced to sacrifice our health by switching to cheaper, less effective medications.

When President Bush signed the Medicare Modernization Act into law in 2003, it offered Medicare recipients the choice to have prescription drug coverage through a Medicare-sponsored prescription drug plan. This was an enormous improvement in Medicare structure, as recipients of Medicare finally could have prescription drug coverage. But it fails people with chronic conditions who have to take expensive medications on a regular basis, as I must. While Medicare Part D is similar in many ways to prescription drug coverage by HMOs and other health insurance companies, the “coverage gap” creates a financial barrier between those of us who can afford the drugs we need, and those of us who cannot.

The coverage gap was created to reduce the cost of Medicare’s Part D coverage. Each year, a yearly limit for Part D is determined. In 2007, the yearly limit was $2400. In 2008, the yearly limit has been increased to $2510. The limit is calculated on total drug costs, which is the sum of what the insurance company pays and the recipient’s co-pay. For example, if a drug costs $250 and the insurance company pays $200 and the recipient pays $50, the amount that goes towards the yearly limit is the full $250.

While in the coverage gap, commonly known as the “doughnut hole”, the Medicare recipient pays for all prescription drugs out-of-pocket. (There are some Medicare part D plans that offer coverage for generics while the recipient is in the coverage gap; however, since these plans tend to cost more per month than most generics cost, they are usually not worth the extra cost.) The recipient remains in the coverage gap until he or she has spent a total of $4050 on prescription drug costs for the year. This amount will be referred to as Coverage Gap Expenditure (C. G. E.) for the rest of this article.

Like the yearly limit, the Coverage Gap Expenditure increases each year. In fact, since Medicare part D first began in 2006, the Coverage Gap Expenditure has increased at a faster rate than the yearly limit. Since 2006, the Coverage Gap Expenditure has increased by $450, 175% the $260 amount by which the yearly limit has increased. When Medicare Part D coverage began in 2006, the yearly limit was $2250 while the C.G.E. was $3600. In 2007, the yearly limit was only increased by $150 to $2400 while the C.G.E. was increased by $250 for a total of $3850. In 2008, the yearly limit was increased by $110 for a total of $2510 while the C.G.E. was increased by $160, making the total $4050. If the current trend holds, each year Medicare Part D recipients will have to spend more and more to get out of the coverage gap.

For Medicare recipients with chronic health problems, especially problems like rheumatoid arthritis which often require expensive medications for treatment, the yearly limit can be breached in a matter of months. The recipient must then choose between paying for all prescription medications out of pocket, which can easily cost well over $1000 each month, or switching to less expensive drugs that may put his or her health in jeopardy. For those whose only form of prescription drug coverage is through Medicare, they can be stuck paying for expensive medications for several months completely out of pocket. For those new to Medicare who did not know about the coverage gap when they signed up, the discovery can be very traumatic, as it was for me.

While the logic behind the coverage gap idea is to encourage people to use cheaper pharmaceutical products when possible, it punishes those who must use expensive medications because nothing else works. For example, for people with rheumatoid arthritis whose disease can only be successfully controlled by biologics like Enbrel, they can fall into the coverage gap within two or three months. Then, they must pay for their medications at full cost for several months until “catastrophic coverage” kicks in, or suffer the potentially disabling consequences of stopping their medications.

For those falling into the gap for the first time, it can be a frightening experience. Many drug companies offer help to those who could not otherwise afford to continue taking medications. The first step one can take in that situation is to contact the drug company or check their website to see if they have any programs that could be helpful. There is also a nonprofit organization called the Patients Access Network which helps those who are under-insured and cannot afford the out-of-pocket expenses of their medical treatment. You can visit their website for more information, or call them at 1-866-316-PANF (7263).

The last resort one can take is contacting the prescribing doctor and explaining to him/her that one is in Medicare’s coverage gap and cannot afford the high cost of one’s current medications. Ask him/her if there are any cheaper medications that one could use. If one is on a medication administered by self-injection, another option is to switch to a medication that must be administered at a doctor’s office or a hospital. Those medications can then be covered under Medicare Part B, which has no yearly limit, instead of under Medicare Part D.

As for me, I am waiting for my pharmacy to contact me and tell me that my $1482 monthly dose of “let’s keep my Rheumatoid Arthritis under control, thank you very much” is ready to be picked up.