How to Try to Avoid the Donut Hole
Did you or someone you know fall into the Medicare Part D “donut hole” this year? The donut hole, or Part D coverage gap, occurs when a person reaches a certain spending limit for their medications ($3,820 in 2019), and must pay more of the costs after crossing that threshold –
37% for generic drugs and 25% for name brand drugs.
Here’s how you can try to avoid the donut hole altogether and get financial assistance if you do fall into the coverage gap.
- The Importance of Shopping Around
With more than 20-30 prescription drug plans in any given geographical area, it is extremely important to work with your Medicare agent to review your current list of drugs, to make sure they are still covered best by your current prescription drug plan. You can make changes to your Prescription Drug Plan or your Medicare Advantage plan during the annual enrollment period of October 15th through December 7th. There are also some Special Election Periods throughout the year, that due to specific reasons, may offer you the chance to switch your plan. (You may want to consult your agent to see if any of these reasons apply to your situation).
- There May Be Help for You
If you cannot avoid the donut hole, you’ll want to explore these options to help pay for your prescriptions:
* State Pharmaceutical Assistance Program (SPAP): Some, but not all, states have a SPAP to help people pay for their medications. Sometimes the SPAP will contribute an amount toward your Part D premium, or it may work to offset your prescription costs.
* Patient Assistance Programs: Brand-name drug manufacturers often have these programs to provide discounts or no-cost medications to those who qualify. You may have to provide proof of income and spending on the prescription to be able to take advantage of these programs.
* Generics: Talk to your doctor about whether any generics may be a good substitute for expensive brand-name drugs. If your medication is in a higher cost tier or not covered on your plan’s formulary (approved drug list), you may want to see if you can ask for an exception to get the plan to cover it completely or at a lower cost.
* “Best” Price: Another strategy is to ask your pharmacist for the “best” price for the prescription. Sometimes costs for drugs may be less if you do not use your insurance. Be mindful that any drug you purchase outside of your insurance will not count toward satisfying your deductible or getting you out of the donut hole, but it may help you avoid the donut hole.
If you would like to review your current Prescription Drug Plan, please call me at (877)777-7055
