Dealing with the Doughnut Hole or Coverage Gap

Beginning in 2011, Medicare beneficiaries will receive a 50% discount on brand-name medications and a 7% discount on generics covered by their Part D plan - while in the coverage gap. Over the next decade, these discounts will gradually increase until by 2020, beneficiaries' co-insurance rate in the gap will be 25%. This means that after their annual deductible is met, individuals will pay 25% of the cost of their covered drugs until they reach catastrophic coverage, at which point they would owe 5%.

If you lapse into your plan’s period of non-coverage – triggered in 2011 when your annual drug costs (what you and your Medicare-approved plan pay for the medications on their approved list) reach $2,840 – you still may be able to minimize your out-of-pocket expenses:

  • First, make sure that your plan itself doesn’t offer extra assistance during the coverage gap. Some Part D policies will continue to cover medications – generally generics only – during the so-called doughnut hole.
  • Ask your prescriber if s/he would consider switching you from brand-name medications to generic equivalents, when appropriate. In addition, make sure your provider has a list of the medications on your plan’s formulary (list of approved medications) because s/he may be able to switch to a less expensive, but similar medication for your condition. Again, you can find this information by visiting our Links page.
  • It’s also good to periodically review all the medications you’re taking with your prescribers to see if any medicines can or should be removed from your drug regimen.
  • Finally, you may be eligible for drug company patient assistance programs to help pay for some of your medications. However, not all drug manufacturers help Medicare beneficiaries with obtaining medications anymore. Ask your prescriber or visit RxAssist for more help. In Durham, you should call Senior PharmAssist.

Note to pharmacists: Pharmacists may reference this guide from the Centers for Medicare and Medicaid Services on closing the coverage gap. In addition, Senior PharmAssist and the state SHIIP office have created a two-page document to help North Carolina pharmacists deal more easily with Medicare Part D for 2011. We hope you find this information helpful.

Just a reminder: If you’re a Medicare beneficiary and did not enroll in a Medicare-approved drug plan when first eligible, and you did not have comparable (also called “creditable”) prescription coverage, you may incur a permanent 1% premium penalty for every month that lapses before you do enroll. With federal and local (Senior PharmAssist) financial assistance and “hands-on” help available, Medicare beneficiaries in Durham – especially seniors – who have no other prescription coverage owe it to themselves to enroll.

Senior PharmAssist and its partners will continue to offer assistance with navigating Medicare-approved drug plans. Seniors, people with disabilities and caregivers should remain vigilant. The NC Department of Insurance has confirmed that confusion related to Medicare changes is creating an environment for financial abuse and fraud.

Beneficiaries should be certain whether a new health plan is truly offering benefits as advertised, without limiting access to needed services. There are also individuals who are posing as insurance agents simply to obtain personal information. Some companies may be “cold calling” seniors to discuss medication benefits, though unsolicited door-to-door sales are not permitted.

In order for these Medicare changes to be most beneficial, many seniors are going to need one-on-one assistance from a trusted, reliable source. Senior PharmAssist continues to be that source for thousands of older adults in Durham. If you live in Durham County and need help obtaining and/or managing your medicines, please call us at (919) 688-4772.