Thursday, June 21, 2012

The Dreaded Medicare Donut Hole

Donut hole:  I love donuts! Mmmm what a sweet circular treat and breakfast staple.  Chocolate, glazed, cinnamon, powdered sugar--there is a plethora of flavors. 

But...from a personal experience here in the call center, I can tell you there is ONE donut hole flavor that doesn't taste or look appetizing at all for people on Medicare Part D.  This time of year, we get so many calls from people falling into the ominous Medicare Donut Hole. 

Can you imagine what it is like to be on a fixed income?  Watching gas prices go up and down, worrying about unexpected expenses, and waking up one day to find that instead of paying 25% for your medicine, it's now 100% out of YOUR pocket!?

For those who aren't familiar, Medicare is a federal health insurance program for Americans 65 and older, people with end stage renal disease, and younger people with disabilities. 

medicare part D
Nothing sweet about the Medicare donut hole.
There is an optional component to Medicare, called "Part D," which is a co-pay prescription coverage plan offered at an additional cost to help people pay for their prescription medications.   However, every year, Medicare Part D recipients fall into a coverage gap (aka donut hole). 

What happens in the donut hole?  Nothing sweet.  

All of a sudden, individuals with Part D go from paying a 25% copay for their much needed medications to paying full retail price. 

Here are a few tips to prepare yourself: 

1. Read the fine print.  I once read somewhere, the only constant thing about Medicare is change.  I couldn't have said it better myself! Make sure you read your coordination of benefits agreement. Read the fine print to make sure everything is in order and if you have questions, ASK!  Also make sure all your medications are covered. Just because your medications were covered last year, doesn't necessarily mean they are covered again this year. 

2. Plan ahead.  If you know you are going to hit the donut hole, ask your pharmacist early in the year what the monthly payment for your current medications will be once you are in the donut hole, including the rebates for brand names and generics.  See if that will be enough to get you out of the donut hole and qualify you for catastrophic coverage.  

If you aren't sure you will hit the donut hole, ask your pharmacist to help you calculate your prescription costs to see if you will or will not. 

3. Be aware of your calendar. Open enrollment for Medicare usually begins every October. Leave yourself enough time to review each plan to see which one is better tailored for you.  

4. Don't be shy. Always consult your pharmacist or plan provider should questions arise. For specific questions, you can call 1-800-MEDICARE or visit the official U.S.  government site for Medicare at

Visit our blog next week to look for what options and resources you have once you or loved ones have fallen into the dreaded Medicare donut hole.

Krysta W.

1 comment:

  1. Wow! I enjoyed reading your blog especially for the donut metaphor. At first I thought it might be another article on donut (the real amazing one).