Donuts to dollars

I saw this item on BJ newsroom retiree Harry Liggett's Facebook page:

"I have hit Aetna's donut hole on prescriptions. I paid $901.27 for drugs just for August. Actos, for diabetes, cost $240.83 for 30 tablets ($8.26 per pill); $195.61 for Levimir insulin, and $106.47 for Novolog insulin."

I emailed Harry and asked what his out-of-pocket costs for 2010 were for prescriptions and he replied:

"I had paid $1,801.76 as of July 31 plus $901.27 for August which totals $2,703.03."

This year's out-of-pocket prescription costs for me (John Olesky) are $1,261.57.

Because we hit the donut hole -- when the total costs of your prescriptions, no matter who pays for it, hits $2,830 in any year -- it automatically triggered a $250 check from Medicare. That pays a little more than one-fourth of Harry's August costs. I also have prescriptions that run more than $250 apiece for a 90-day supply.

Remember, once you hit the donut hole, you pay 100% of brand-name prescriptions for the rest of the year.

The law, written mostly by pharmaceutical lobbyists, uses two math formulas. To get to the $2,830 donut hole threshold, all the costs of all the prescriptions count, no matter who pays for them. Aetna gets BJ retirees to the donut hole quicker by listing a higher "cost" for some prescriptions than what you would pay at a local pharmacy. And the Aetna "cost" is up to four times more than what the same prescription costs in Canada.

Once you hit the donut hole, the math changes. Then Aetna (and the law written by the lobbyists) only counts what YOU paid for prescriptions. Instead of starting at $2,830, you usually start at $300 or so. Since you pay 100% for brand-name drugs till you reach $4,550 for the year, few people ever get out of the donut hole.

Aetna plays other games, too. That's why Centers for Medicare & Medicaid Services (CMS) imposed sanctions April 21 on Aetna. That means Aetna can't add new customers until CMS is satisfied that the wrongs have been righted. The Hartford, Conn., company switched its Part D prescription drug coverage from an open formulary to a closed one of payment tiers and failed to properly transition some customers from drugs covered under the old formulary to those covered under the new one. Also, some customers received incorrect denials of medications, which delayed their prescriptions.

Click on the headline for Cheryl Powell's BJ story on 1.8 million Ohioans affected under the new health care law.