Medicare Part D “Donut Hole”

How To Avoid the Coverage Gap & Cost

One of the more complicated and frustrating aspects of Medicare is the Medicare Part D Gap Coverage, more commonly known as the “donut hole”.  Medicare Part D is a federal program put in place to help Medicare beneficiaries with the costs of their prescription drugs.  Remember that Medicare doesn’t provide plans to individuals; rather someone must find a plan through an insurance carrier that is contracted with Medicare Part D.

Please note this about the Medicare Part D “donut hole” – not everyone goes into it.  If you do not take any medications or you are only prescribed a couple each month (outside of expensive maintenance drugs), you probably will not reach the “donut hole”.  The “donut hole” is reached when a beneficiary’s initial coverage limit is met – each year the limit amount is set by Medicare.  What Medicare does is track a beneficiary’s True-Out-Of-Pocket costs (TROOP), which is the retail cost of the medication being taken.  What a beneficiary pays and what the plan or insurance carrier pays.

If a medication’s cost can be lessened or found for a lesser price, the likelihood a beneficiary reaches the “donut hole” might be avoided or prolong when a beneficiary gets into it. There are ways to cut costs on your prescriptions should you be one of the many Medicare beneficiaries that consistently reach the “donut hole” or think you might reach it based on your prescriptions. Many Medicare Part D prescription drug plans offer the option of mail-order for three months supply.

The parameters of the savings vary, but in most cases by utilizing the mail order option a beneficiary could pay for two months worth for three months supply.  Other plans might offer two and half months payment for a three-month supply. Some insurance carriers negotiate with preferred pharmacies to offer the same cost-savings options as its mail-order.   In order to take advantage of these savings, sit down with your doctor and inquire which medication you take can be prescribed for a three-month supply.  Contact the pharmaceutical company directly if you are on expensive maintenance medications to see if it offers cost-saving programs.

Also, ask your doctor to prescribe the low-cost generic form of your medications.  Not every medication has a generic form nor does every form of generic work for every individual.  That is why it is necessary to discuss these options with your doctor. Once you have a better understanding, it is vital to sit down with a Medicare Part D trained and certified professional.  Healthcare Services of Illinois’ (HSOI) licensed insurance specialists are Medicare Part D trained and certified and regularly guide its clients through the Medicare maze ensuring that they understand their options, cost structure, coverage and find the most appropriate plan.