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Lowering Costs in the Medicare Doughnut Hole

New health care law shrinks the gap this year

At last, help is here for people who fall into the "doughnut hole" — the hated gap in coverage that is unique to the Medicare Part D prescription drug benefit. Enrollees no longer have to pay the whole cost of their drugs while in the gap because, under the new health care law, it begins to shrink this year. Here's how the new deal works:

Q. How will my drug bills be reduced?

A. You fall into the Part D coverage gap if the total cost of your drugs since the beginning of the year reaches a certain level: $2,840 in 2011. At that point, in previous years, you would have paid 100 percent of the cost of your drugs in the gap, unless you had other coverage. And only when you'd spent a large amount out of pocket since the beginning of the year ($4,550) could you climb out of the gap and qualify for low-cost catastrophic coverage until the end of the year.

But in 2011 you'll spend much less of your own money in the doughnut hole. You get:

  • A 50 percent discount on brand-name and biologic drugs, including insulin and vaccines, contributed by their manufacturers.
  • A federally subsidized 7 percent discount on generic drugs and Part D-covered supplies used to administer insulin.

Over the next 10 years these discounts will get larger, so that by 2020 you will pay no more than 25 percent of the cost of any Part D-covered drugs in the doughnut hole.

Who gets the discounts?

Anybody who falls into the doughnut hole and is enrolled in a "stand-alone" Part D drug plan (the type mostly used by people in traditional Medicare); those using a Medicare Advantage health plan that provides drug coverage; or those enrolled in any Part D plan sponsored by a current or former employer or union.

Will I qualify for these discounts if I receive Extra Help?

No. People with limited incomes who receive low-cost prescription drug coverage under the government-subsidized Extra Help program already have year-round coverage without a doughnut hole.

How do I get the discounts?

You don't need to apply for them or fill out any paperwork. The discounts will be automatically applied at the pharmacy or, if you get your prescriptions through mail order, by your plan's mail-order service.

Does the discount apply to all Part D drugs?

Under the new law, drug manufacturers must provide the doughnut hole discounts on all their brand-name and biologic drugs if they wish to participate in the Part D program. Medicare officials say that the manufacturers of more than 99 percent of brand-name drugs used by Medicare beneficiaries have agreed to provide the discounts.

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