Understanding changes to coverage in 2015 and ways to manage your donut hole

Most Medicare prescription drug plans have a coverage gap, also called a donut hole, which places a temporary limit on what the drug plan will cover for prescription medications.

Patients who fall into this gap are sometimes surprised and often dismayed at the reduction in their prescription coverage. Each year the allotted coverage that is allowed before falling into the gap changes. According to information found on Medicare.gov, in 2015, the amount is $2,960. In 2016, the amount will increase to $3,310. These thresholds appear to be significant. However, the thresholds include total cost of the drugs, not just the patient’s cost.

Once a patient reaches the coverage gap this year, the website says, they will be required to pay 45 percent of the plan’s cost for covered name-brand prescriptions. The discount will be applied to the price the patient’s particular plan has set with the pharmacy for that specific medication.

The site also says although patients pay just 45 percent for name-brand prescriptions, 95 percent of the cost will be calculated to determine if the patient has closed the coverage gap. Patients will receive notice of the amount that they have met toward the gap in each Explanation of Benefits (EOB) statement.

Nearly 10 million people are now enrolled in six of the 10 largest Medicare Part D prescription drug plans, and those people are facing premium increases next year ranging from 11 to 52 percent, according to information provided by Medicare. Three other large plans, with nearly 3.5 million members, will actually drop their premiums next year by 13 to 31 percent.

According to the website, open enrollment for Medicare runs from Oct. 5 through Dec. 7, giving beneficiaries the chance to find the best deals for next year by comparing coverage and out-of-pocket costs in their current plans — whether it’s Part D drug plans, Medicare Advantage HMOs and PPOs — with what other plans have to offer.

Our Pharmacy has a lot of Medicare patients and many others who have no insurance. With our competitive prices and member benefits, we make going to the pharmacy affordable and easy. Pharmacy staff members are there, not only to fill your prescriptions, but also to help you with your pharmacy needs. Stop by today because we’re always happy to help.

Items that do not count in the coverage gap include:

    • The drug plan premium
    • Pharmacy dispensing fees
    • Payment for medications not covered by insurance

Items that do count in satisfying the gap include:

  • Annual deductible, co-insurance and copayments
  • Discounts on name- brand medications in the coverage gap
  • Any payments made in the coverage gap