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Ask Ms. Medicare

Can a Drug Cost You Less in the Doughnut Hole?

Yes — in certain circumstances

How to tell whether your medications will cost less

Certainly, not all brand-name drugs in all Part D plans are going to cost less in the doughnut hole, even with the 50 percent discount, than they did earlier in the year when fully covered. The vast majority, in fact, still cost more in the gap.

Whether or not you get lucky — as the person who asked this question did — depends on these factors:

  • How expensive your drug is at your plan's full price. A drug that costs hundreds or even thousands of dollars a month will almost always cost more in the doughnut hole (even with the 50 percent discount) than any copay.
  • What copay your plan requires you to pay for any given drug. The higher the copay, the more likely it is that you'll pay a lesser amount in the doughnut hole after 50 percent of the full price has been deducted, as required by law.

Keep in mind that different Part D drug plans charge widely varying copays — even for the same drug. (The variation among plans is often more than $10 and in some cases can be as high as $100 for a month's supply.) That's why it always pays off to compare plans during open enrollment — Oct. 15 to Dec. 7 — according to the drugs you take. The possibility of one or more of your medications costing less in the doughnut hole is just one more reason to make this comparison.

You can do this by using Medicare's online plan finder. If you enter your ZIP code, the names of each of the drugs you take, their dosage and how often you take them, the plan finder identifies the plan that covers your drugs at the least out-of-pocket cost — including premiums, deductibles, copays and what you would pay in the doughnut hole if you fall into it. Go to Medicare's website and click on "Compare Drug and Health Plans."

In 2012, the doughnut hole begins when you and your plan have spent $2,930 on your drugs since the beginning of the year. If your drug costs are high enough, you get out of the gap when your out-of-pocket costs (not including premiums) reach $4,700 since the beginning of the year. The 50 percent manufacturer discount on brand-name drugs counts toward this limit, even though you don't pay them yourself.

Also of interest: Moving in and out of the doughnut hole. >>

Patricia Barry is a senior editor at the AARP Bulletin.

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