Over 4 million Americans, up to 38 % of Medicare Part D enrollees, may go into the “donut hole” and it isn’t sweet! Insurance companies and government bureaucrats prefer to call this the “coverage gap”. Regardless of what you choose to call it, the Medicare Part D prescription drug coverage gap/donut-hole can be a real shocker and a nightmare for many senior citizens on fixed incomes. It is estimated that fewer than 5% of those that fall into the donut hole ever come out before January 1 of the following year. The reason? A lot of people stop taking all or some of their medicine because they can’t afford it.
Why is there a coverage gap or “donut hole” in Medicare Part D coverage?
The simple answer is the cost of full coverage. When the politicians designed Part D a few years ago they had to make choices. Their goal was to give all Medicare enrollees help with their drug costs and expand that benefit for low income enrollees through Low Income Subsidy (LIS) and provide coverage for those patients with catastrophic drug costs. The estimated cost of a Medicare Part D plan without a coverage gap was far above the total amount authorized by Congress hence the need to insert the gap which the patient is responsible for.
As far as I am aware, there are no Part D plans available in the United States that provide 100% coverage for brand name drugs without the gap. Most plans will provide coverage for generics throughout the year but not brand name. This is the time of year when a lot of seniors start “falling into the hole”. Here are some tips to help you manage the Donut Hole dilemma:
1.) Ask your Medicare Part D insurer if your income is low enough to be eligible for 100% coverage, also known as Low Income Subsidy (LIS).
2.) Apply for Prescription Assistance Programs. The manufacturers of many drugs offer these programs as does the Partnership for Prescription Assistance (888-477-2669). Caution: Assistance programs are available only if your income is low enough to qualify.
3.) Use generic drugs whenever available. Use them during you initial period too, not just during the donut hole. Purchasing generics could keep you from ever falling into the Medicare Part D coverage gap. Be sure to purchase you medicines from a pharmacy that is in your plan’s network.
4.) Contact your Social Security office or your state’s health department to ask if you might qualify for any programs that give extra help if your drug costs are very high.
Medicare Part D is a wonderful thing for most Medicare beneficiaries. To make it work for you, educate yourself as much as you can about the program. In the next posting we will explore in greater detail the workings of Medicare Part D.