Medicare Part D Donut Hole

Will the EpiPen Controversy Put You Into the Medicare Part D Donut Hole?


            In the newspaper both TV and online that the cost of an EpiPen has gone up astronomically to over $600.  I am leaving my company benefits and going to Medicare effective January 1, 2017. 

            I am relatively healthy but am an insulin dependent diabetic and take Benicar for blood pressure $40 copay and Lipitor for cholesterol which is a $20 copay.

            Is there something I should do to be prepared when I leave my company benefits?  Thanks, Rod from Tomball, TX   

Great Question Rod:

            I am amazed at what is being discussed regarding the EpiPen issue, once you begin to look at how the cost has risen from $57 in 2007 to over $600 in today’s prices.

            The average American who has employer benefits does not realize what the cost of prescriptions drugs are until they begin using Medicare Part D and have the experience of reaching the “donut hole”.

            Currently, you have a co pay of $40 for Benicar, but the true cost of Benicar is $181 and the Lipitor’s true cost is $261 not the $20 co pay.  You did not mention which diabetic insulin you are using, if it is Novolog Flexpen, its true cost is $568.

            When one is enrolled in a Medicare Part D plan, they are astonished to find out that Medicare Part D drug plans use true cost of the covered prescription drugs not the co pays to determine when one reaches the “donut hole”.

            Here is how the Medicare Part D plan works:
  • Currently, there is a $360 deductible for a Part D plan and the amount that must be met is $3310 from the “true” cost of prescription drugs to begin the “donut hole” .
  • Once the $3310 is met, then one enters the famous “donut hole” and must spend $4,850 out of your pocket before going back to using your prescription drug plan again.  While in the “donut hole” you will pay 45% of the “covered” brand name drug and the manufacturers pick up the balance of 55%.  Could be why the cost is going up? You will also pay 58% of generic drugs cost. Most generic drugs can be more affordable than brand name drugs.
  • What if the brand name prescription is not “covered” on your plan? Then you pay 100%. While doing prescription drug planning, our team does everything we can to make sure all prescriptions are covered on your Medicare Part D plan.
  • Once you have maxed out the $4,850, then you leave the “donut hole” and are in catastrophic coverage. You will pay 5% of those specific brand name and generic drugs.
  • Visit the website and put all of your prescriptions in their system. It will advise you which Medicare Part D plan fits your prescription drug needs.


            The cost of prescriptions plays a big part of Medicare Part D planning.  If an EpiPen was the old cost of $57 instead over $600,you might not go into the “donut hole” as fast.

            Congress made it a law that Medicare cannot negotiate the cost of prescriptions. The law is for the 50 plus million Americans that are currently on Medicare.  This does not count the 10,000 baby boomers that are turning 65 everyday for the next 17 years.       

            Toni King, author of the new Medicare Survival Guide®. A simple guide that puts Medicare in “people” terms. On sale now at Email questions to or call 832/519-TONI (8664).

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