Toni:
Last year, my mother got into the “donut hole” in October. I can see from the Part D statement she receives that she is rapidly approaching the donut hole and it is only the beginning of May. None of her drugs have changed from 2013.
She can afford her co pays of $150 per month, on her statement from her Part D plan it says the prescription drugs cost is $780 per month. I’m confused.
She does not qualify for “Extra Help” because she makes about $300 too much in her Social Security check. Please give me some ideas! Thanks Sam from Alvin, TX
Hello Sam:
Your mother’s prescription drug problem is typical of the average person on Medicare. She can afford her $150 co pays, BUT… has no idea that the true cost of her prescription drugs is $780 each month. Once her Medicare Part D prescription drug plan and the co pays she pays totals $2,850 in 2014 for her covered drugs, then she is in the famous “Donut Hole” or coverage gap.
In 2014, those who have a Medicare Part D plan receive a 52.50% discount on “covered” brand name prescription drugs that counts as out of pocket spending and helps them get out of the “Donut Hole”.
A Medicare beneficiary will pay 47.50% of the brand name prescription and the prescription drug manufacturer will pay 52.50% of the “covered” drug. Everyone who gets in the “Donut Hole” must spend $4,550 out of pocket for the year to get out of the “Donut Hole” or coverage gap. When they are out of the “Donut Hole”, then they enter catastrophic coverage and pay a small co pay for each prescription drug until the end of the year.
January 1 of each year, the process starts all over again, with a new Medicare Prescription Drug plan and different costs, deductibles and a new Donut hole. No one knows what the numbers will be for 2015 until later this year.
*** 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 which includes your co pay to Medicare. Most think it is only 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 cost drugs because once you get in the “Donut Hole”, you have to spend $4,550 for 2014 to get out of it.
Toni’s Tips to help you stay out of the Donut Hole or not get in it as soon!
1) Use www.medicare.gov when selecting a Medicare Part D plan whether it is your first time or changing during Medicare’s Annual Enrollment Period in the fall. This is an accurate way to view the cost of drugs and which plan and pharmacy is most cost effective.
2) Talk to your doctor or doctors about which brand name drugs can be changed to generics.
3) Get samples from your doctor.
4) See what generics are in a $4 or $5 generic prescription drug programs at HEB, Wal-Mart, and Kroger etc… Pay for the generics out of your pocket. To get their discounted price you only need a prescription from your doctor.
5) Use your Medicare Part D plan for your brand name drugs and expensive generics. You do not have to put every prescription on your Medicare Part D plan.
6) Contact the Prescription Assistance Program in Lake Jackson at 979/285-1430 which has saved over $64 million dollars helping people get their prescriptions at affordable prices when people can’t pay for them.
7) Go to www.tonisays.com and sign up for Toni’s newsletter and receive a “free” copy of the new Medicare Prescription Drug Survival Guide e-book version.
Toni King is the author of Medicare Survival Guide is available only at www.tonisays.com and not sold in bookstores. Toni is an advocate/consultant for those “Confused about Medicare”. Email questions to www.tonisays.com/ask-toni or call 832/519-TONI (8664).
