The beginning of the "doughnut hole"
Yesterday I had my first customer come talk to me about his medicare coverage. He spends quite a bit of money in the pharmacy, but he had opted for a plan which had the "doughnut hole." Now. the details of each plan's doughnut hole vary, but basically they all revolve around the magic $2250 number. There are some common misconception about this so-called doughnut hole, and he had fallen victim to both!
1. $2250 is the number that your plan pays out, not the total of your copayments.
That means that while you may pay $28 for a prescription on your AARP/United Healthcare plan, how much of your benefit the prescription is actually eating up may be hidden from you. Talk to one of the pharmacy personnel, and they can help you figure out how much of your benefit a given prescription has used.
2. If you have chosen a plan that is not robust enough for your needs, you may be able to change it.
What this gentleman also did not know was that he wasn't going to be stuck paying out-of-pocket. It might be possible to upgrade your plan during the year, depending on who administers your benefits. Some may charge a penalty, others may require a letter of intent. If you or a loved one has chosen a plan that didn't take into account all of the medications that ended up being needed, you may wish to contact your benefits administrator to see about changing to a higher tiered plan. Some companies allow it, and some do not — but it is an avenue worth exploring. If there is a fee, it may be worth it to pay for it. This change would go into effect the first of the following month.
For instance if you altered your existing coverage today, June 6, your changes will go into effect on July 1.
Most Part D providers offer two or three tiers — AARP/United Healthcare being a notable exception. Level 1 is usually the least expensive plan, and it is suitable for most people. Tiers 2 and 3 usually have provisions to cover the doughnut hole, and it is probably worthwhile looking into these plans if you spend a lot of money on prescription drugs. You may pay slightly higher copayments and monthly premiums, but you will more than make it up for the long term.
As always, I recommend checking out the Medicare website, particularly their plan search tool. Be sure to be specific, and enter your medications, and dosages so the plan can really help you choose the plan that's best for you. At the end, it will present you with a list of plans ordered by yearly cost that cover the medications taken. The yearly cost is what it will cost you or a loved one in terms of premiums, copayments, and lack of coverage if a donut hole is ever reached. While you can't change which company you go with now, you will be able to after November 15 when open enrollment begins again.
Other things to consider
From a clinical standpoint, Part D has been a resounding success; many seniors are filling more prescriptions than they ever have in the past. Unfortunately, some seniors are getting a little too "script happy." That is, filling prescriptions not because they need them, but simply because they can.
For many seniors, this isn't a problem, but if you or your loved one subscribes to a plan with a doughnut hole, and their annual drug costs are very close to the limit, this can easily push them over. Stocking up on eyedrops and other medications taken as needed adds up fast, so I would advise only filling them when they are actually needed. The time could come when you or your loved one needs expensive antibiotics but cannot afford it because they burned up their benefit too quickly on medications that they might not have needed right away.
Remember, the plan resets itself January 1. Stocking up might not be a bad idea in December, but it certainly can be in June!
[tags]medicine, pharmacy, medicare, medicare part d[/tags]
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[...] Reading articles like this irritates me more than just a little bit. I have written extensively about the coming Part D doughnut hole already. Furfaro, a disabled heart-transplant patient, hit the doughnut hole last month when he tried to fill a prescription for two medications. Instead of two $25 co-pays, the pharmacist charged him $661 and $329 for the prescriptions. [...]
Pingback by OnThePharm » Hitting the Medicare doughnut hole early — June 13, 2006 @ 8:33 pm