Toni:
This year, my mother got into the “donut hole” in September. It has financially devastated her and she almost stopped taking her prescriptions. She can afford her co pays of $80.00 per month, but it shows on her statement that the true prescription drugs cost is $650.00 per month. How can I help her stay out of the “Donut Hole or not get in it so fast? Thanks in Advance…Susan from West U.
Hello Susan:
Your mother’s prescription drug problem is typical of the average person on Medicare. She can afford her $80.00 co pays, BUT… has no idea that the actual cost of her prescription drugs is $650.00 each month. Your mother pays the co pays for the Part D plan and the Plan pays the remaining RX cost until the total prescription drug cost reaches $2,930 in 2012 for her covered drugs, and then she is in the famous “Donut Hole” or coverage gap.
Beginning in 2011, as a result of Healthcare Reform, you will not longer have to pay the full cost of your prescription drugs when you enter the donut hole. Those who have a Part D plan receive a 50% discount on “covered” brand name prescription drugs counts as out of pocket spending and until she gets out of the “Donut Hole”. She pays 50% of the brand name prescription and the prescription drug manufacturer also pays 50% of the “covered” drug. She will also receive a discount of 14% for “covered” generic drugs. If a prescription is not “covered” on her Part D plan, then she will pay 100% for that prescription and not have the 50% discount.
Everyone who gets in the “Donut Hole” must spend $4,700 out of pocket for 2012 to get out of the “Donut Hole” or coverage gap. When she is out of the “Donut Hole”, she enters Catastrophic coverage and pays a small co pay for each prescription drug until the end of the year and on January 1 of each year, the process starts all over again.
Most people on Medicare that get in the “Donut Hole” worry how they will afford their prescriptions and also pay their lights, car payment, rent not to mention buy some Christmas or birthday presents for their precious grandchildren.
*** What confuses the average person is that the total cost of the prescription is reported to the insurance company and they report the total amount to Medicare. Most think it is the
co pay that is being reported. I have a very hard time trying to help people understand that you do not have to put every prescription on your Medicare prescription drug card. Use your card for your high priced drugs because once you get in the “Donut Hole”, you have to spend $4,700 to get out of it.
Here are some of Toni’s Tips to help you stay out of the Donut Hole or not get in it as soon!
1. Do Prescription Drug Planning. One tool I have found to be very helpful is AARP’s Donut Hole Calculator which is located at http://doughnuthole.aarp.org. Once you put your prescriptions in their system, it will tell you when you will go in the “Donut Hole” and if there is any alternative less expensive drugs for that one or if there is a generic.
2. Talk to your Doctor about what brand name drugs can be changed to generics.
3. See what generics are part of $4 or $5 generic prescription drug programs at HEB, Wal-Mart, and Kroger etc… Pay for affordable generics out of your pocket. You do not need a Prescription Drug plan to get their discounted price you only need a prescription from your doctor.
4. Get samples of your prescriptions from your doctor. This can keep you from going into the “Donut Hole” as soon.
Toni King is an advocate/consultant for those “Confused about Medicare”. Email questions to asktoni@medicaretruths.com or call 281/830-3896. Visit her website www.medicaretruths.com.
