Paying Less for Drugs in the Part D 'Doughnut Hole'

My plan doesn't normally cover one of my drugs but agreed to cover it because it was medically necessary for me. Will I get a discount for this drug in the gap?

Yes. If a plan grants coverage for a drug that's not on its formulary — usually in response to the patient's doctor's request for an exception to its rules — this drug is considered a covered drug for the purpose of discounts in the doughnut hole and counts toward the dollar limit that gets you out of the gap. But no exceptions can be granted for a drug made by a manufacturer that does not participate in the discount program.

What if my plan already gives some coverage for my drugs in the gap?

Your plan's coverage is applied first, and the discounts are applied to the remaining amount.

Example: You are enrolled in an "enhanced" Part D plan that covers 40 percent of the cost of your drugs in the gap. You go to the pharmacy to fill a prescription for a brand-name drug that costs $100. The plan pays $40 of this amount, leaving $60 as your share. But after the manufacturer's discount is applied, you pay $30 plus a dispensing fee of, say, $2. The $40 that the plan paid does not count toward the spending limit that gets you out of the doughnut hole. But the rest — the whole $62 — does count.

What if I'm enrolled in a state pharmacy assistance program?

You still get the discounts in the doughnut hole. They will be applied to the price of your drugs before the state assistance kicks in. This is also true for other programs that provide help to pay for Part D drugs, except for Extra Help.

What if I already get assistance from a drug manufacturer?

You should check with the manufacturer's patient assistance program to see if its policy has changed.

How will I know if the proper discounts have been applied?

An explanation will be included in the regular statements you receive from your plan. If you have reason to think that you haven't received the correct discounts, call the number shown on your membership card. If you disagree with the plan's explanation, you can use the standard appeals process to resolve the issue. You can also call Medicare at 1-800-633-4227 to file a complaint.

Patricia Barry is a senior editor with the AARP Bulletin.