Dealing with the Doughnut Hole or Coverage Gap

In 2010, Medicare Part D enrollees who land in the coverage gap (doughnut hole) and do not qualify for the federal Low-Income Subsidy or Medicaid will receive a $250 rebate check from the U.S. Department of Health and Human Services. A word of caution: If you qualify for this one-time rebate, a check should come to you automatically - approximately 45 days after you reach the coverage gap. BE ON THE ALERT for anyone who calls or shows up at your door requesting personal information like your social security number to "certify your eligibility."

Starting next year, 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%.

In the meantime, if you lapse into your plan’s period of non-coverage – triggered in 2010 when your annual drug costs (what you and your Medicare-approved plan pay for the medications on their approved list) reach $2,830 – 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 20 percent of Medicare Part D policies in 2010 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.

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, state (NCRx) 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 other agencies mentioned above 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.