Part D Coverage Gap Alert
By: Patricia Barry; Source: AARP Bulletin Date Posted: 2006-09-13 13:32:00-04:00
By Patricia Barry
September 2006
Once you've reached the coverage gap in your Medicare drug plan and are paying full price for your medications, only drugs bought from your plan's in-network pharmacies will count toward the $3,600 out-of-pocket expense limit needed to get you out of the "doughnut hole."
Medicare officials say drugs bought elsewhere don't count, an apparent reversal of policy. In August 2005 officials of the Centers for Medicare & Medicaid Services wrote to AARP that "if beneficiaries believe they can get better discounts from other sources than the rates negotiated by the plan...they are responsible for informing their plans of those expenditures" so they can be applied to the $3,600 limit.
CMS acknowledges that the new policy, which AARP opposes, is "not explicitly pointed out" in the law or its regulations but says it's "implicit" in the definition of a "covered drug" as one listed on a plan's formulary and bought at an in-network pharmacy.
AARP says the policy makes sense only before the coverage gap is reached. But once people fall into the doughnut hole, they're paying premiums, not getting any coverage and paying 100 percent out of pocket. Those who shop around to buy cheaper drugs, AARP analysts say, are being penalized for being wise consumers.
Beneficiaries are advised to check out prices at other pharmacies in their plan's network, including chain stores that often give the steepest discounts.
Additional Related Links
Medicare Part D: In and Out of the Doughnut Hole (June 2006)
New Q&A on Rx Plans (March 2006)
New "Extra Help" Income Limits (February 2006)
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