For Oldsters Reaching the Doughnut Hole

evan-amos photo
evan-amos photo

If you were born when Ike was president, as I was, and you take prescription drugs, you will have learned, or you will soon learn about the ‘doughnut hole’. When it comes to the doughnut hole, I am the opposite of an expert. I know nothing about it or how it came to be, so this entry is based solely on my own experience, but I hope what I have learned may be helpful for those as clueless as I am.

The doughnut hole is a payment limit that kicks in when you’re old and gray, and once you reach it, you have to pay 25% of the cost of your prescriptions. If you are taking generic drugs, that probably won’t amount to much, but if you’re taking a brand-name drug it can be a real wallop.

I take Eliquis, a blood thinner, to reduce the risk of stroke, because I had A-fib. Eliquis costs more than $17,000 a year.

Every state has a program to help seniors when they reach the doughnut hole, and in Massachusetts, that’s a plan called Prescription Advantage. Enrolling in this plan reduced my monthly copay for Eliquis from more than $150 a month to $18 a month, and the plan is free.

I learned about it from the SHINE Program, which helps oldsters with insurance. 

When I first walked into the SHINE office and met Lorraine York-Edberg, I heaved an enormous sigh of relief. Here at last was someone who was on my side and wasn’t trying to sell me something.

Lorraine helped me enroll in Prescription Advantage back in August, getting on the computer, pulling up my information, calling the prescription drug plan that I pay for (different from Prescription Advantage) and helping me fill out the forms.

It gets complicated because I have a meager nest egg from which I derive a meager income. PA eligibility is based on income and not assets, so I qualified.

This week I went to the pharmacy to pick up my Eliquis, and they charged me $407 for a three-month supply. That’s a wallop for someone with a meager income, so I called my drug plan (no luck there) and I called PA and the lady calmly explained that PA wouldn’t kick in until I had spent more than $4,000.

Funny thing: when Lorraine called them, they found they had made a mistake and I’m getting a refund!

The SHINE Program is located in the offices of LifePath in Greenfield and they have been an enormous help to this clueless oldster.