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the medicare drug plan
6 Key Facts

1. Anyone on Medicare can get coverage regardless of income or health.

2. You are not obligated to enroll, but there may be consequences if you don't sign up when you are first eligible to do so.

3. To get Medicare drug coverage, you must select one approved private drug plan among many offering different choices. There is no single government plan.

4. Is your income limited? If you qualify for a part of the program known as "Extra Help." you'll pay very little for your medications.

5. Are your drug costs very high? You'll pay no more than 5 percent of the cost of each prescription after you've spent a certain amount of money out-of-pocket in any one year.

6. Do you have better drug coverage already? You probably won't need Medicare's Part D coverage. But it's wise to check.

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Medicare Prescription Drug Coverage Guide

Part 3: Moving In and Out of the Doughnut Hole

Navigating the Part D coverage gap

What if I can’t afford the cost of my drugs in the gap?

First ask your doctor whether any other drugs on your plan’s formulary would be just as effective for your medical condition. Using lower-cost medications, such as generics or similar but older brand-name drugs, will substantially reduce your costs at any time, not just in the gap.

If you don’t have additional insurance (for example, from an employer plan, a state pharmacy assistance program or Extra Help) that pays some or all of your costs in the gap, you may consider other (non-insurance) sources of help. These include:

  • Free or low cost drugs from assistance programs run by pharmaceutical manufacturers.
  • Free or low-cost drugs supplied by local medical clinics, charities or patients’ organizations.
  •  Lower-cost drugs from Canada or other countries.

Must I continue to pay my monthly premiums during the gap?

If you stop paying premiums, your plan will likely terminate your contract, leaving you without drug coverage. In that case, if you join a Part D plan again in the future, you’d have to pay a late penalty according to the number of months you were without coverage.

How will I know where I am in relation to the gap?

The monthly statement you receive from your plan must explain how near you are to entering the coverage gap or, if you’re already in it, how much more you need to spend on your drugs this year before qualifying for catastrophic coverage.

If you use the Prescription Drug Plan Finder tool to choose a drug plan — by entering the names of the meds you take, plus their dosages and how often you take them — you can see a bar chart that indicates your total out-of-pocket expenses month by month over the whole year for each plan. The chart shows if and when you’ll fall into the doughnut hole and, if so, how long you’ll stay in it.

Patricia Barry writes the AARP Ask Ms. Medicare column and is the author of  Medicare for Dummies (Wiley/AARP, October 2013).

You May Also Like: Your Medicare Starter Kit

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