Ups and Downs of Medicare Part D

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April 9, 2008 - 12:20 pm email to a friend printer friendly view / write comments

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LeahMSW

by Leah deRoulet, MSW

After covering the highlights of Medicare parts A, B, and C in the last post, we’ll now move to Part D, the plan that provides outpatient prescription drug coverage. If one can afford it, it is usually best to purchase the plan that covers most of the medications you are taking, and this might be available through the Medigap supplemental plan you choose. Then you have one plan that covers both Parts B and D. In cases where this is not affordable, and you do not have prescriptions for many oral drugs, you might be able to get by with an inexpensive Part D supplement plan. I have one patient who pays $25.50 per month for her plan, as well as the co-pays and the deductibles required for the plan. But this is a very reasonable plan. I have other patients who are paying $95.00 or more for their plans, but some of these more expensive plans also covered the dreaded “donut hole“, or coverage gap that occurs after a certain amount of money is spent by Medicare to cover the cost of the drugs. Although there may be some differences in charges relative as to how much money should be spent, for the most part there are 4 areas of Part D that must be traversed. The first one is the initial deductible. The second one is the area where Medicare pays its share of the costs except for the co-pay, which is 25% of the cost of the drugs. The third area is the coverage gap or donut hole, where Medicare pays absolutely nothing until the patient accrues a total amount of out of pocket spending, which can be as low as $3,800.00, including the deductibles and the co-pays and cost of the drugs while the patient is in the donut hole. At the point at which the out of pocket spending meets the necessary monetary criteria (in 2008, that figure is $4,050.00), Medicare then picks up all of the cost of the drugs at a 95% payment rate, and the patient pays a minimal co-pay, usually no greater than $5-10. This is returned to zero again at the beginning of every year, when the plan starts fresh for the next year, and the deductible (and donut hole) kicks in again.

One way to reduce costs in Part D is to utilize generic drugs wherever possible. Most commonly used drugs in oncology have a generic form, and requesting that your physician use the generic is always a good idea. There are a percentage of Medicare recipients who never reach the donut hole because their need for oral medications is small, or they always use generics. Their out of pocket spending never reaches Level 3 of the Part D plan. If it does, and you are unable to meet the entire cost of the coverage, there are ways to get assistance with the costs. Comprehensive information on federal, state, and private assistance programs in your area are available on the website www.benefitscheckup.org. Also, look into Pharmaceutical Assistance Program on the Medicare web site. Many of the major drug manufacturers do offer assistance for people enrolled in Medicare Part D. If you do have Medicare and have limited resources, you may qualify for extra help paying for your prescription drugs. Go to the Social Security website or call 1-800-772-1213. If you are unhappy with your choice of the Part D plan, you may always change your plan between November 15th and December 31 of each year. Keep using your Medicare drug plan card, even while in the coverage gap. Using the drug plan ensures that you’ll get the drug plan’s discounted rates and that the money you spend counts towards your catastrophic coverage. Of course, if you receive free drugs from an assistance plan, you will not be able to use your drug plan card. Do the research or contact someone to assist you to determine what may be a better plan for you. Also, one advantage of some plans is that they may cover the donut hole: they may be more expensive in the short run, but not later on. Most Part C or HMO plans do cover the donut hole, which may one reason they are the choice of so many Medicare enrollees. So, you can see how important it is to do your homework!

All Medicare drug plans are different, and certainly vary from state to state. You should call your plan to find out how the coverage gap will work for you. This is a complex decision, and often does not become clear until one is on the plan and receives the benefits booklet! I wish you luck in negotiating this maze of rules and regulations. If you have a need for more information, please write me about your concerns.

Till next time,

Leah

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