25 July 2022
The clerk at the pharmacy was just alarmed as we were by the price increase in Joyce's Santyl prescription. She confirmed it was the same doctor, same quantity, same prescription as our June 7 order, which cost us $94, not the $360.59 this order was being charged.
And yes it's in the drug formulary (or drug list) of accepted drugs.
She had to talk to the pharmacist to get the billing detail. He looked Joyce up and said she was in the Medicare Part D donut hole. If you recall, we went through this in June when we demonstrated we were nowhere near the donut hole.
So the clerk did a little more investigating into the billing and while she did, we looked up Joyce's prescription benefits status on the Kaiser Web site using her phone.
Kaiser said she was in the donut hole now.
Kaiser said she was in the donut hole now.
But how could that be? She hasn't spent anywhere near the $4,430 threshold.
It turns out it isn't what she herself has the value of the drugs she has been prescribed. And Santyl isn't the only pricey drug she's been prescribed this year. There was that home IV-antibiotic infusion in February and a few extravagant oral antibiotics along the way, too.
So this $1,784 order pushed her over the $4,430 limit of the initial benefit phase. By about $266.
What happens in the donut hole?
Well, it's technically a coverage gap, meaning Medicare isn't going to pay mauch. Depending on what "Tier" Kaiser classifies Santyl (generally Tier 4), she will pay 25 percent of the full cost of the medications ($446 for Tier 4 Santyl) until you hit $7,050.
As I understand it, Joyce will be liable for roughly $2,980 in drug costs before she gets out of the coverage gap.
This six-tube order of Santyl will last 42 days or so. Which will get us into September.
The next order (which will get almost through October) will cost her either $446 (25 percent) or $1,785 (full cost), but either way leaving $1,195. That still leaves two months (60 days) to go. One more order of six tubes, if we stretch things out. And only $590 of that covered as we exit the donut hole and enter what's called the catastrophic coverage level.
You can say that again.