Medicare Part D – Prescription Coverage

As many of you know, the “donut hole” is when you exceed $2700 a year in drug costs. Your coverage then resumes after your yearly out of-pocket drug costs reach $4350. Understanding the following may keep you out of the “donut hole”.

Your Medicare Part D plan keeps tabs of your total prescription costs. This includes both what they paid and the co-pay that you paid. So if a prescription costs $100, your plan pays $75 and you pay, $25, the entire $100 goes towards your tab. So, once your tab reaches $2700, then you hit the “donut hole” at which point you pay 100% until your yearly out-of-pocket drug costs reach $4350, you then will have catastrophic coverage of which your plan will then pay 95%.

So, here are a couple of ideas to help you choose the right plan and how to manage the “donut hole”.

Be aware that open enrollment started on November 15th and closed on December 31st. But you can change your plan up until March 2009. It is easy to say, “Look for the plan that best fits your needs.” However, you need to evaluate what your needs are first. To get started, ask yourself the following questions:

How many medications am I taking now?

Make a list of your current medications. Many Medicare Part D plans will cover a review of your medications once a year. Through a review of your medications or (Medication Therapy Management-MTM), the pharmacist can possibly reduce the amount of your medications, reduce the cost through generics, or OTC’s (especially while in the donut hole), and improve your health, by pointing out harmful medication interactions.

What are my current co–pays ?

As of January 2009, it is certain that medication prices will be increasing. This will mean higher co-pays in some plans. Those people in standard plans where cost sharing is 25 percent of the cost of the drugs will be faced with steeper out-of-pocket costs. (Beware pharmacies that say they will write off co-pays! This is illegal!)

Does the plan have a good formulary and does it cover my medications?

Many will be surprised to find out that come January 2009, that their medications have been dropped off of the formulary and they are no longer covered.To find the best plan that fits with your current medications, visit, go to “Formulary Find” and list your medications.

Does the plan communicate well with me, my doctor and my pharmacy ?

It is important to know the rules associated with benefits for certain drugs or classes of drugs. If the Part D provider is not communicating with the doctor or pharmacy, there could be a higher cost for your medication or no coverage at all.

Do I need an Assistance Program ?

There are programs that offer a little “extra help” for those who meet certain financial criteria; visit the Social Security website to see if you qualify. For other assistance look at the SHINE program. Extra help is available for some people with limited income and resources. It will pay for all or most of the monthly premiums and annual deductibles and lower the prescription payments related to plans. The extra help could be worth up to $3600 per year. Many people with limited income and resources qualify for these big savings and don’t even know it. To learn more about the Medicare prescription drug plans and special enrollment periods, call 1-800-MEDICARE (1-800-633-4227), or visit Medicare also can tell you about agencies in your area that can help with Medicare prescription drug plans.

When looking for a plan be aware of their ability to do the following:

  • Communicate well with the customer, doctor & pharmacy
  • Make timely payments
  • Offer prior authorization for medications
  • They have a good formulary