Don’t get stuck in Medicare’s coverage gap

| Kathryn Jones

Editor's note: This article first ran in 2016, but we've updated it in time for the 2018 Open Enrollment period.

Not long ago, we posted a blog letting you know that enrollment for Medicare Part D runs from Oct. 15 through Dec. 7. We also offered some tips for shopping for a new prescription plan.

Now, let's talk about affordability. 

Medicare beneficiaries might be familiar with a term called "the donut hole." This is basically a temporary limit on what your drug plan will cover for your prescriptions, and it starts up when your out-of-pocket costs reach a certain amount. In 2018, once you and your plan have spent $3,750 on covered drugs, you're in the coverage gap and you may see your out-of-pocket costs for treatment increase dramatically. 

Once you enter the coverage gap, you will pay 35 percent of the plan’s cost for covered brand-name drugs and 44 percent of the plan’s cost for covered generic drugs until you reach the end of the coverage gap, which happens when you spend a total of $5,000. That’s when you enter the “catastrophic coverage” phase and then pay only 5 percent coinsurance on your drugs through the end of the year.

The U.S. Department of Health and Human Services estimates that more than 25 percent of Part D participants stop following their prescribed regimen of drugs when they hit the donut hole. 

Please don’t do that. Here are three tips that could help you lower your drug costs:

Look into "Extra Help"

You should know that some people with low incomes and modest assets are eligible for “Extra Help” from the Social Security Administration to pay the costs of their prescription drug coverage. If you qualify, you can receive big savings on your out-of-pocket costs and you get to stay out the donut hole.

This year, certain people qualified if they have an annual income of less than $18,090 individually (or $24,360 for a married couple) and had up to $13,820 in resources (or $27,600 for a married couple). Even if your annual income is higher, you still may be able to get some help. And if you didn’t qualify last year, you can always reapply for Extra Help at any time if your income and resources change. 

Contact your medicine's manufacturer

Another suggestion is to call the manufacturer of your medication. You might qualify for assistance from that company if your income is low or if you don’t have insurance.  

Talk to an NPF Patient Navigator

Finally, for one-on-one assistance, contact NPF's Patient Navigation Center. Our navigators can explain concepts like the donut hole, connect you to your drug manufacturer's assistance program and help you find other solutions to manage drug affordability.

Ask us a question, email us, or call 1-800-723-9166 (option 1) to talk to a Patient Navigator.

You can also request a free Health Insurance Quick Guide from the Patient Navigation Center. This guide outlines specific information to help you assess your health care needs for the upcoming year, compare Medicare plans and select the best Medicare plan to reduce your out-of-pocket costs.

For more ideas, visit the Medicare webpage and get tips on how to lower your drug costs.


Driving Discovery, Creating Community

This year, we’re celebrating 50 years of driving efforts to cure psoriatic disease and improve the lives of those affected. See how far we’ve come with this timeline of NPF’s history. But there’s still plenty to do, and we can’t do it without you! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funding to promote research into better treatments and a cure by joining Team NPF, where you can walk, run, cycle, play bingo or even create your own DIY event. Contact our Patient Navigation Center for free, personalized support for living a healthier life with psoriatic disease. And keep the National Psoriasis Foundation going strong by making a donation today! Together, we will find a cure.

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