What to Do If You Drop Into The Part D Doughnut Hole

What to Do If You Drop Into The Part D Doughnut Hole

Unless you enrolled in a Part D drug plan that offers coverage for the gap or "doughnut hole," you will pay 100% of the costs in this gap in coverage until your total out-of-pocket costs reach $3,600.  The cost of the gap, however, may be more than you can handle.  What can you do?  Here are five tips from the Medicare Rights Center, the largest independent source of Medicare information and assistance in the United States.

  • Apply for Extra Help, a federal program that helps pay for some or most of the costs of Medicare prescription drug coverage, if your income and assets are low enough to qualify.
  • Enroll in your state's pharmaceutical assistance program.  Over a third of all states offer assistance to help fill in the gaps in the Medicare drug benefit.  Some have chosen to provide "wrap-around" assistance and help with all out-of-pocket expenses including premiums and co-payments.  Others are offering premium assistance or rebate programs.  What your state program pays toward your drug costs will count against the total $3,600 in out-of-pocket costs that you must pay in order to get catastrophic coverage (payments for premiums, however, do not count toward this amount).  Check with your state plan for more information.
  • Apply for assistance from a certified charity that helps pay your out-of-pocket costs.  What a charity pays for your drug costs will count toward the $3,600 out-of-pocket costs you must pay in order to reach catastrophic coverage.  To be able to do so, however, the charity cannot be affiliated with a specific pharmaceutical company.  Support from a traditional pharmaceutical manufacturer's patient assistance program will not count toward your out-of-pocket costs to reach catastrophic coverage under Part D.
  • Keep "wrap-around" retiree drug coverage.  Talk to your former employer to find out if your current retiree drug coverage will pick up any of the costs that Medicare does not.  However, what your employer or retiree insurance pays for your drug costs will not count toward the $3,600 in out-of-pocket costs you must pay in order to get catastrophic coverage.
  • Switch to an enhanced Medicare private drug plan that offers the Medicare drug benefit with lower out-of-pocket costs.  Enhanced Medicare private drug plans (whether drug-only plans, or Medicare private health plans, like HMOs and PPOs) generally charge higher monthly premiums than basic plans but may offer better benefits.  These may include eliminating the deductible and/or coverage gap, having a broader list of covered drugs (formulary) and offering lower co-payments.  Some plans may also cover drugs that are excluded from Medicare coverage by law, such as benzodiazepines. You will have to determine if the extra premium is offset by any additional benefits.

Note: If you buy a drug that is not on your plan's formulary or if you buy it from a pharmacy not in your plan's network, you will have to pay the full cost yourself and it will not count toward your $3,600 out-of-pocket maximum.

Visit the BenefitsCheckUp web site at: https://ssl2.benefitscheckup.org/ and perform a BenefitsCheckUpRx screening to find out what federal, state and private prescription drug assistance you may be eligible to receive.  Upon completing the screening, you will receive a recommendation of the right combination of benefits for you.  You will also receive instructions on how to apply.  No information is saved—once you leave the web site, your personal information is deleted!

The above information is from Dear Marci, a free, weekly newsletter designed to keep you in the loop about health care benefits, rights and options for older Americans and people with disabilities. To sign up for Dear Marci click here www.medicarerights.org/subscribeframeset.html.

Dear Marci is a service of the Medicare Rights Center (MRC) (www.medicarerights.org), the largest independent source of Medicare information and assistance in the United States.  Founded in 1989, MRC helps older adults and people with disabilities get good, affordable health care.

June 2006