Joan, an 81-year-old resident of the Chicago suburbs, recently fell into the “donut hole.” That’s the name for a Medicare coverage gap that requires people to pay more for their medications after the individual and their drug plan have spent a certain amount — $4,130 in 2021 — for covered drugs.
While in the donut hole, individuals temporarily pay up to 25% of the plan’s cost for every covered prescription drug.
For Joan, who asked that her last name not be used for privacy, the donut hole is debilitating. It means she needs to pay hundreds of dollars out-of-pocket each month for costly diabetes medications.
Rising drug prices are hurting many older adults across the Chicago area. As prices rise, they are looking for options to help manage the costs.
Dealing with drug costs
With drug prices skyrocketing, 7.5 million seniors lack the funds to pay for their medications, according to Gallup’s 2019 report, The U.S. Healthcare Cost Crisis. The cost of prescription drugs presents a hardship for many seniors, the report says.
“My husband and I worked, planned, and saved for our retirement, but it isn’t enough to cover those kinds of costs for prescriptions,” Joan says.
Joan brought her concerns to her doctor, who referred her to Matthew Biszewski, PharmD, a clinical pharmacy specialist with NorthShore University HealthSystem.
To explore options to help patients pay for the rising costs of prescriptions, Biszewski brainstorms with patients and a team of physicians, nurse practitioners, and a social worker. Such assistance, Biszewski says, is common for pharmacists who work in specialty clinical settings, such as oncology.
Resources available to help patients often include patient assistance programs offered by drug manufacturers, government agencies, and pharmacies, as well as changing to a formulary alternative.
Working with Biszewski and his colleagues, Joan learned recently that she was approved for nearly $1,000 a month from a drug manufacturer program. “I didn’t realize there were patient assistance programs. I feel lucky. Matt was so helpful,” Joan says. “It’s important to talk with your doctor and ask questions.”
Some people may mistakenly think they make too much money to qualify for such assistance, even if drug costs are taking a toll on their finances. “I encourage them not to assume and apply,” Biszewski says.
Many older adults depend on prescription drugs to manage their chronic conditions. Yet, the prices can be prohibitive. Some seniors report cutting their pills in half to make the medication last longer, or they stop taking their medicine altogether.
For instance, about 34 million Americans have diabetes, and about 29% require insulin to manage their disease. People with diabetes typically need two to three vials of insulin per month, at about $175 to $300 a vial.
The national costs are staggering. Medicare spent $183 billion on prescription drugs in 2019. In 2015, oral prescription drugs for cancer cost $18 billion nationally, according to a 2020 study published in the American Association for Cancer Research journal. Projecting for population aging and growth, research estimate that those costs will jump to $25 billion.
Reasons for skyrocketing costs of prescription drugs are complex, including a lack of competition, lack of price transparency, and patent laws that stipulate how long new, more expensive drugs can remain on the market before generic, less expensive medicines are developed.
To save money, choosing generic drugs can help, as can buying medications that are preferred on the formulary and using manufacturer coupons, Biszewski says. Although, physicians prescribe newer, more expensive medication as part of their patients’ treatment programs.
Medicare Part D plans and Medicare Advantage plans offer different medical and drug coverage for varying prices, says Joe Gladis, United Healthcare market sales manager. Each year, people should review their plans and potential alternative plans with the help of a professional versed in insurance and health benefits, he says.
New technology can help patients improve their health and lower medical costs. Rebecca, a suburban Chicago resident with diabetes, found that technology has helped her better control her diabetes.
Rebecca, who asked that her last name not be used for privacy, worked with Biszewski and his team when she started using a continuous glucose monitoring system, implanted just below her skin. The monitor allows her to check her blood sugar with a painless, one-second scan instead of with finger stick tests, which Rebecca dreaded, multiple times a day.
After Rebecca switched to the monitoring system, she checked her blood sugar levels more frequently, which led to better management, a reduced need for insulin, and, in turn, less money spent on the drug.
“I was able to lower my blood sugar levels, as result of being able to constantly see my blood sugar numbers and know if I needed to adjust what I was going to eat,” Rebecca says. “I’m so happy with the results, and I feel better.”
Drug prices aren’t going down anytime time soon. Although costs continue to increase, people’s awareness of options to reduce their drug spending is rising, too.