CFS, Fibromyalgia, Disability – and the Donut Hole

At the age of 41, I never would have dreamed that I would have to worry about Medicare and “Medicare Supplement Insurance” and “the Donut Hole” that I have heard the commercials talking about. I actually didn’t really pay much attention when those commercials would come on the TV because I thought it doesn’t apply to me so I don’t need to pay any attention to it. Well � I got hit hard the middle of December with the realization that my husband was losing his job and company health insurance. All of a sudden, having to find new health insurance right before Christmas became a majorly stressful time for me because I had always had either health insurance through my husband’s employer or through my own employer when I was still working full-time.

So there I was, trying to deal with the stress of the holidays, and my husband finds out that his job was ending – along with the health insurance that we have had for the past 15 years.  My husband’s idea of helping me through all of this was just telling me that “everything will work out”.  He would say, “I know you will find a way to pull it all together because you always do.”  But the stress of it all really took a major physical toll on me.  It was just way too much to deal with at one time.  Trying to deal with my illnesses, the craziness at work around the holidays, all of the holiday shopping and preparing here at home, and then trying to find new insurance on top of it all was overwhelming. 

What I finally found was the most cost effective way to go was to actually split the three of us up, which was surprising.  At first, I thought that keeping us together would be cheaper but it wasn’t.  My husband went on COBRA, I went on Medicare and got a Medicare supplement plan & prescription plan, and Logan will be going on the low-cost CHIP program.  I spent the last few days of the year in at the Social Security office and on the telephone trying to get all of my insurance and prescription plans in place. 

The hardest part of researching my health insurance was actually the prescription plan coverage.  I went through the Medicare handbook, and called several of the prescription plans that were highly recommended, and had to give them a list of all of the medications I am on.  They would then tell me the tier the drug was in, the co-pay (if any) per month or quarter, and then there is a monthly premium for each of the drug companies you pay as well.  It wasn’t until I was on the phone with the very last prescription plan carrier that they mentioned to me that I would fall into the “donut hole” or “coverage gap” probably around the middle of the year because of two of the medications that I am taking – my pain med. and my muscle relaxer.  None of the other CSR’s I had talked to said anything to me about this. 

What I found out was that the pain medication that I currently take I would pay $600.00 a year for under my husband’s insurance plan ($50/month co-pay).  With the plan I am on now, I would pay $35/month, but around June, I would end up paying almost $300/month for the same drug.  It’s the same for the muscle relaxer.  I would only pay a few dollars a month for it until June, but once June gets here, I will have to pay over $200/month for it!  And that would be throughout the rest of the year!  They explained that because of the retail cost of these drugs along with my other prescriptions, I would use up my allotted amount by the middle of the year.  The only way for me to avoid falling into this donut hole or coverage gap is to get cheaper medications that RETAIL for less but basically do the same job as the ones I’m on now.  I’ve been trying to get my doctor to change my medications but she keeps calling me back saying that she is already prescribing the generic so it shouldn’t be a problem.  She isn’t understanding that it is the retail price of the drug that is counted in this whole coverage thing that is the law now for Medicare.

I have an appointment with my doctor on Thursday so I am hoping I can get her to understand.  I can’t pay that kind of money every month for medication – that is just impossible.  The company I went with gave me a list of alternative pain medications and muscle relaxers that would keep me out of the donut hole.  Hopefully she will work with me.  If not – I will have to try and suffer without I guess.

If you are going on disability and have to go on Medicare, please make sure you research the prescription companies well and ask if you will fall into the coverage gap and how much your medications will be if that happens.  Once I found out about the coverage gap from the last company I called, I called each of the others back, gave them my medication lists again and asked them:

• Will I fall into the donut hole with these medications?
• If I do, when will that happen? (They should be able to give you the approx. month that you will hit the gap)
• If in the gap – what medications are costing the most (retailing for the most)?
• Can you provide me a list of alternative/cheaper  medications that will keep me out of the gap that I can give to my doctor to approve?
• If I still fall into the gap, what would these medications cost? 

The plan that I went with I pay a monthly fee and I don’t pay anything out of pocket for 90% of my medications.  The only medication I should have to pay anything for at the pharmacy (if the doctor approves the changes) is my thyroid medication and that is because my endocrinologist does not want me taking a generic of Synthroid.  He will not sign the prescription for generics. 

It was a lot of work, but it’s done now and hopefully everything will work out for the best.  We all just have to get used to new insurances and each of us on different prescription plans but it was the best way for our family to go.  Even with all of the stress, it was so worth it to do all of the research.  I learned a lot during those two weeks and now I can breathe a little easier.