Nightmare For Many Senior Citizens – The Donut Hole!

Over 4 million senior citizens, up to 38 % of enrollees, may “go into the hole financially” or, “donut hole”, what insurers and bureaucrats prefer to call the dreaded “coverage gap”. Regardless of what you choose to call it, the Medicare Part D prescription drug coverage gap “donut-hole” can be a real shocker and a nightmare for many senior citizens on fixed incomes.

What is the Medicare Part D donut hole? Essentially, few enrollees are exempt from the coverage gap unless they purchase an expensive Medicare drug plan that offers 100% coverage or are otherwise exempt due to extremely low income.

Otherwise, you will have to pay 100% of your drug costs, rather than a small co-pay, once your annual prescription costs reach $2400 and until you pay $3850 out of your own pocket. What costs are added up to reach this $2400 threshold? – the actual cost of your prescriptions basically – add your deductible ($250), your drug co-payments and the amounts paid for your medicines by your Medicare plan. Once these add up to $2400, you are on your own until your out-of-pocket cost reaches $3850. What costs paid by you are added up to reach the $3850, before you can return to making only co-payments for prescriptions? – your deductible, your co-pays in the initial period and payments made by you for covered prescriptions during the gap from a pharmacy in your plan’s network. NOT counted: your monthly premiums, payments for drugs not in your plan’s formulary, drugs purchased from a pharmacy not in your plan’s network, drugs purchased from foreign countries or drugs received from a patient assistance program or free samples from your doctor. * Note: Dollar limits are scheduled to increase yearly.

Why is there a coverage gap or “donut hole” in Medicare Part D coverage?

The simplified answer is the cost of full coverage. Plan advocates had to make choices. Their goal was to give all Medicare enrollees help with their drug costs and expand that benefit for low income enrollees and those with catastrophic drug costs. The estimated cost of a Medicare Part D plan without a coverage gap was far above the total amount authorized by Congress.

What can I do to get through this coverage gap without purchasing an expensive 100% coverage plan?

1.) Ask your Medicare Part D plan administrator if your income is low enough to be eligible for 100% coverage

2.) Apply for prescription assistance programs. Ask your druggist. The manufacturers of many drugs offer these programs as does the Partnership for Prescription Assistance (888-477-2669). Caution: Assistance programs are available only if your income is low enough to qualify.

3.) This is a free program you should certainly check out: Anyone can get a free prescription drug discount card that most pharmacies accept by either printing one at or requesting one by e-mail at [email protected]. There are similar very good programs that offer prescription discount cards, some may have eligibility requirements and some have enrollment fees. The above has neither. All programs can save you a lot of money depending on your medication.

4.) Use generic drugs whenever available. Use them during you initial period too, not just during the donut hole. Purchasing generics and utilizing the cards mentioned above could keep you from ever falling into the Medicare Part D coverage gap. Be sure to purchase you medicines from a pharmacy that is in your plan’s network.

5.) Contact your Social Security office or your state’s health department to ask if you might qualify for any programs that give extra help if your drug costs are very high.

Medicare Part D is a wonderful thing for most of us. To make it work for you, educate yourself as much as you can about the program. Start by asking your druggist for advice. He should be able to help you select the best plan for your specific needs.