The Doughnut Hole in the Medicare Part D Prescription Drug Program: What You Should Know for 2009
73The "doughnut hole" in the Medicare Part D prescription drug program is not getting any smaller in 2009. For those on the drug plan D who have high prescription drug costs, you're out of luck getting coverage when you reach the coverage gap. In 2009, this gap, or "doughnut hole" as it's called, is the amount you pay above $2,700 in drug costs and below $4,350 out of pocket.
What does this mean? Well, besides paying for the cost of the prescription drug plan plus your copayment or coinsurance on drug costs to $2,700 (that number includes both what you've paid and what the plan has paid), you're now paying 100% of your drug costs until you've dug deep into your pocket and shelled out $4,350, including your deductible and copay (but not the cost of the plan--that, unfortunately, doesn't count toward the limit).
After you've paid $4,350 out of pocket, you're in better shape, since you're on catastrophic drug coverage for the rest of the year and only responsible for 5 percent of your prescription drug costs.
All told, the annual dent in the budget of a senior or disabled person whose drugs are costly is significant and scary.
How to Find Plans That Cover Your Prescription Drugs
Use Medicare's Prescription Drug Plan Finder to find plans that may be a better match for your needs. Unfortunately, not many plans offer coverage in the "donut hole"--and those that do only cover generic drugs. But you may find plans that have better coverage for the prescription drugs you take and that have pharmacies available in your area.
The Annual Enrollment / Election Period for Medicare Part D
From November 15 through December 31 every year, you may switch to a different Part D plan for the next year, starting in January
What Options Do You Have if Your Medicare Program Has a Coverage Gap?
It's not a pretty picture, but there may be options for you to cover you during the period of the doughnut hole coverage gap.
For those patients who are on the prescription drug program (Part D) with a coverage gap, Medicare recommends you:
- Switch to lower-cost medications or generic drugs, if your doctor thinks they would work as well.
- Seek out local or national charity programs--for example, the National Organization for Rare Disorders--which might have programs that could belay some of the drug costs.
- Seek out any assistance programs offered to Medicare Part D patients by the pharmaceutical companies.
- Get Extra Help from Social Security--you may be eligible if you have a low income and savings. Visit Social Security's website, or call 1-800-772-1213 or TTY 1-800-325-0778. If you qualify for Medicaid as well as Medicare, you automatically are eligible for Extra Help.
The Doughnut Hole: Medicare Part D in the News
- Medicare open enrollment: time to make sure you're in the right planLexington Clipper-Herald21 hours ago
(ARA) - Of the more than 45 million people relying on Medicare for health care coverage, many may be paying for a plan that doesn't meet their needs or is too expensive.
- ‘Show me’ first, ClaireBuffalo Reflex5 hours ago
One of the selling points of the Democrats’ healthcare reform bills is that they claim they are going to cut half a trillion dollars of Medicare costs by getting rid of waste, fraud and inefficiency.
- Coast Lines Nov. 27, 2009Santa Cruz Sentinel6 hours ago
Coast Lines SANTA CRUZ Card offers prescription savings Santa Cruz County plans to launch a new prescription drugs savings program to help people who are uninsured or require drugs not covered by their insurance.
Medicare Part D Research
- Potential opportunity cost of neglecting to annually reassess Medicare Part D standalone prescription drug plan offerings: The price of contentment?
Related Articles Potential opportunity cost of neglecting to annually reassess Medicare Part D standalone prescription drug plan offerings: The price of contentment? J Am Pharm Assoc (2003). 2009 November-December 1;49(6):777-782 Authors: Walberg MP, Patel RA Objectives: To determine the (1) potential cost difference (opportunity cost [OC]) to Medicare-eligible beneficiaries enrolled in the lowest-cost standalone prescription drug plan (PDP) in 2007 between the cost of such plan in 2008 and the lowest-cost plan in 2008 and the (2) percentage of PDPs with the lowest estimated annual cost (EAC) in both 2007 and 2008.Design: Descriptive exploratory study.Setting: United States during 2007 and 2008.Patients: 50 patients were randomly selected from a database of Medicare-eligible beneficiaries.Intervention: Pharmacy claims records for each study patient were obtained during the period January 1 to June 30, 2007. Patient medication profiles were generated using these data and entered into the Medicare Plan Finder Tool (www.medicare.gov) to obtain the EAC of each PDP from 2007 and 2008 in all 34 Medicare Part D regions.Main outcome measures: The 2008 EAC of the lowest-cost PDP from 2007 was recorded. OC was determined by subtracting the 2008 EAC of the lowest-cost PDP in 2008 from the 2008 EAC of the lowest-cost PDP in 2007 for each patient in each region. The percentage of PDPs that had the lowest EAC in both 2007 and 2008 was recorded.Results: The 2008 EACs of the lowest-cost PDPs from 2007 were significantly higher (P < 0.001) than the lowest-cost PDPs of 2008 within all 34 Medicare regions. The mean OC ranged from $276 to $562 nationally. Only 12% of plans were the lowest-cost PDP in both 2007 and 2008.Conclusion: Medicare beneficiaries should reevaluate PDP offerings annually during the open enrollment period; failure to do so may increase avoidable out-of-pocket costs. PMID: 19926558 [PubMed - as supplied by publisher]
- First-year Medicare Part D prescription drug benefits: medication access and continuity among dual eligible psychiatric patients.
Related Articles First-year Medicare Part D prescription drug benefits: medication access and continuity among dual eligible psychiatric patients. J Clin Psychiatry. 2009 Nov 17; Authors: West JC, Wilk JE, Rae DS, Muszynski IL, Rubio-Stipec M, Alter CL, Sanders KE, Crystal S, Regier DA OBJECTIVE: This study provides national data on medication access and continuity problems experienced during the first year of the Medicare Part D prescription drug program, which was implemented on January 1, 2006, among a national sample of Medicare and Medicaid "dual eligible" psychiatric patients. METHOD: Practice-based research methods were used to collect clinician-reported data across the full range of public and private psychiatric treatment settings. A random sample of psychiatrists was selected from the American Medical Association Physician Masterfile. Among these physicians, 1,490 provided clinically detailed data on a systematically selected sample of 2,941 dual eligible psychiatric patients. RESULTS: Overall, 43.3% of patients were reported to be unable to obtain clinically indicated medication refills or new prescriptions in 2006 because they were not covered or approved; 28.9% discontinued or temporarily stopped their medication(s) as a result of prescription drug coverage or management issues; and 27.7% were reported to be previously stable on their medications but were required to switch medications. Adjusting for case mix to control for sociodemographic and clinical confounders, the predicted probability of an adverse event among patients with medication access problems was 0.64 compared to 0.36 for those without access problems (P < .0001). All prescription drug utilization management features studied were associated with increased medication access problems (P < .0001). Adjusting for patient case mix, patients with "step therapy" (P < .0001), limits on medication number/dosing (P < .0001), or prior authorization (P < .0001) had 2.4 to 3.4 times the increased likelihood of an adverse event. CONCLUSIONS: More effective Part D policies and management practices are needed to promote clinically safer and appropriate pharmacotherapy for psychiatric patients to enhance treatment outcomes. PMID: 19925748 [PubMed - as supplied by publisher]
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