How This Couple Uses GoodRx to Avoid the Medicare Donut Hole

Chuck and Lisa, a retired couple from Washington, are among the 40% of Medicare patients who find themselves in the Medicare Part D donut hole and couldn’t afford their medications. Luckily, they are now able to get the treatments they need with the help of GoodRx.

The Medicare “donut hole” refers to the prescription benefits coverage gap between a patient’s initial coverage limit and their out-of-pocket maximum. Once in the donut hole, patients will have to pay more for the same medications, regardless of whether they are generic or brand-name.

Medicare 2018 enrollees are responsible for at most 35% of the costs for brand-name drugs and 44% for generic drugs while they’re in the coverage gap. Though the donut hole has been narrowing every year since the Affordable Care Act (ACA) was passed in 2010, patients still have to shoulder $5,000 in total out-of-pocket costs before they reach their next coverage period — called catastrophic coverage — and many people find that they either cannot afford it, or it’s not worth it. That’s where GoodRx comes in.

Chuck’s wife, Lisa, has had several chronic conditions for most of her life, so it wasn’t exactly a surprise when she reached the donut hole at the beginning of April this year. The medications she needs for her fibromyalgia and multiple autoimmune disorders (including lupus) are either pricey brand-name drugs or generics that are still prohibitively expensive.

As Chuck mentions in his tweet, GoodRx saves them 83% on her mycophenolate (Cellcept) tablets alone. They check GoodRx regularly to see if they can find savings on her other medications as well.

For Lisa, being able to afford her medications is the difference between being able to get out of bed and not. She stopped being able to work as a registered nurse 15 years ago due to her health issues, but she’s taken up fused glass art and even has her own kiln for her creations!

Chuck, who has arthritis and is also on disability, is a guitar collector and musician, but he’s had to sell his guitars in order to afford their medications and make ends meet. He says he only started looking for drug discount options at the end of last year, when his Medicare prescription plan lapsed and he needed something to help him through December.

Chuck was surprised to find that the GoodRx prices matched his Medicare co-pay prices during the initial coverage period. “I looked at discount plans online along with the prescription program provided by our usual pharmacy. Comparing prices, it was clear that using GoodRx at another pharmacy was the best option.” He expects to hit the donut hole later this year himself. When that happens, he’ll be using GoodRx to reduce the amount he has to pay for his medications.

The concept of the donut hole is confusing to many people — Chuck included. “I can’t get my head around how it all adds up. All I know for sure is that my wife’s current prescription is $380 or so without help. It’s a no-brainer to use GoodRx.”

But changes to the donut hole are coming. The already-shrinking Part D coverage gap was scheduled to close in 2020, but a new budget deal signed in February this year has pushed that deadline up to 2019. It’s unclear whether that will translate to insurers requiring higher premiums and deductibles, but one thing’s for sure – GoodRx will be working to help Americans afford their medications.