Help! I’m going to hit the “Donut Hole” – What can I do?

Why Are My Prescriptions Costing So Much More?
Many persons covered by Medicare Part D Prescription Drug Plans or Medicare Health Plans have discovered that they now have to pay more for their prescription drugs when they have entered the “coverage gap” or “donut hole” of their drug coverage. This occurs when the total cost of your covered drugs (what both you and the plan have paid) exceeds $2,930.00 in 2012. (Follow this link for a chart that shows how the donut hole is shrinking as a result of the Health Care Reform enacted in March, 2010.)

If you enter the donut hole, in 2012 you will be responsible for a copay of either 50% of the full cost for covered brand name drugs (plus a dispensing fee) or 100% of the full cost for brand name drugs not covered by the 50% discount plan, and a copay of 86% of the full cost for generic drugs.

“Full cost” is the actual cost of any prescribed drug (not just your copay). “Full cost” can vary by drug plan. The Medicare Plan Finder lists the full cost of drugs for each plan. You can follow this link to go to the Plan Finder page on the Medicare website.

Your Part D Prescription Drug Plan will not begin paying again until your out-of-pocket drug costs for the year (not including your monthly drug plan premium or anything your plan paid toward your drugs) exceed $4,700.00 in 2012. At that time, you have “catastrophic coverage,” and you will pay the higher of either 5% of the full cost for your drug or $2.50 for generic drugs and $6.30 for brand name drugs. When you are in the donut hole your plan will track your spending on covered drugs – as long as you continue to use your plan card and use pharmacies covered by the plan when purchasing prescription drugs.

Should I try to save money on my medications now?
If your out-of-pocket drug costs are likely to hit $4,700.00 before the latter part of 2012, it probably makes sense to continue obtaining your drugs through the plan pharmacies. If you will benefit by the catastrophic level of drug coverage, you may save more than you would by shopping elsewhere while you are in the donut hole. Remember: only medications purchased using your plan card through plan pharmacies count toward being able to move through and out of the donut hole so you can take advantage of catastrophic coverage. This is a complex calculation; we recommend that you make an appointment to see a HICAP counselor for assistance; follow this link for a list of Contra Costa HICAP counseling sites.

Many persons, however, will enter the donut hole in the latter part of the year and will find that it is unlikely that their out-of-pocket drug expenses will exceed the the amount that would allow them to benefit from catastrophic coverage. If this is true for you, it makes sense to try to keep your prescription drug costs as low as possible.

How can I reduce my prescription costs while in the donut hole?

1. If there is any possibility you are eligible for prescription drug “Extra Help”, also called the “Limited Income Subsidy”, apply through Social Security. If you qualify, your prescription drug costs will be greatly reduced.
   
   Individuals with incomes below $1,361/month and resources less than $12,640 should qualify. Married couples with incomes below $1,839/month and resources less than $25,260 should qualify. Resources do not include the home you live in or your vehicles, personal possessions, burial plots, or irrevocable burial contracts.
   
   Application can be made on-line at the Social Security website, https://secure.ssa.gov/apps6z/i1020/main.html. You can also get phone assistance in making an application at 1-800-772-1213. If you have a hearing disability, call the TTY number at 1-800-325-0778.


2. Could you qualify for other programs? Veterans may qualify for VA drug coverage. Individuals with some chronic conditions may be covered by special programs. Get information about other resources at the California Health Advocates’ website: http://cahealthadvocates.org/drugs/resources.html.


3. If possible, with your doctor’s agreement, switch from brand to generic drugs. Many brand drugs do not have generic equivalents. If yours does not, ask your physician if there are any alternative generic medications that might accomplish the same purpose as the brand drug. You could save a lot.


4. Ask your physician for drug samples, if available.


5. For the remaining brand drugs, try to qualify for any pharmaceutical company Patient Assistance Programs that might apply. Each pharmaceutical company sets its own rules for who qualifies. Some automatically disqualify anyone with Medicare or other coverage, even if they’re in the coverage gap. Some will allow people in the coverage gap to apply. Nearly all have income limitations. It can be a bit of a hassle to qualify for these programs, but once qualified, a patient can get an expensive drug for a very low, or even no cost.
   
   An excellent resource for identifying applicable Patient Assistance Programs for brand-name drugs, learning their rules, and making application is the website: www.rxassist.org.


6. One organization, Xubex Pharmaceutical, has a program that allows an individual to get one month’s supply of many brand-name drugs for free. Information and the application are available at: https://secure.xubex.com/FreeMedication.aspx.


7. For some generic drugs the simplest and least expensive option is a special program that some pharmacies offer. For example, some offer certain generic medications for copays as low as $4 for one month supply or $10 for three months supply. Drugs covered include commonly prescribed drugs for hypertension, cholesterol management, diabetes and many other conditions. For more information check with your local pharmacies and mass merchants to see if they have low-cost copays on the generic drugs you take.:
   


8. Two other programs offer generic drugs through the mail at low prices: RxOutreach (sponsored by Express Scripts) and Xubex Pharmaceutical Services. These plans cover many generic drugs not covered by the plans mentioned above. You can get a 90 day or longer supply of a drug for a greatly reduced price – the price may vary with the program, drug, and quantity. There are income limitations; they may be less restrictive than the Patient Assistance Programs. One advantage of these programs is that you can complete one application that serves for multiple prescriptions. Information and an application for RxOutreach is at www.rxoutreach.com/. Information and an application for Xubex is at: http:/www.xubex.com/.


9. NeedyMeds.org is a resource that lists programs that assist with the costs of medicine and healthcare for children, adults, and seniors. There are links to Patient Assistant Programs (PAP) for brand name and generic medications; drug coupons; discount drug cards; free and low-cost clinics; disease-based assistance; diabetic supplies; medical equipment; state-sponsored programs; programs for children; and more. Go to www.needymeds.org/.

Exploring these cost-saving options may seem like a lot of trouble, but the potential savings are considerable. It could be well worth your effort.

Disclaimer: This article is not able to incorporate all of the discount prescription drug programs, sources of low cost prescription drugs and useful information on this topic. Its intention is to provide examples of services and useful strategies. The Health Insurance Counseling and Advocacy Program (HICAP) does not provide medical advice.