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What counts toward the dollar figure to reach the donut hole
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Medicare & Insurance
What counts toward the dollar figure to reach the donut hole
Share Medicare dos and don’ts, including eligibility and supplemental insurance.
I contacted my Medicare Part D insurance carrier to ask about how the money is counted to reach the donut hole. I was reviewing what some prescriptions cost the insurance company which I assume is the
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Cat:91a4afbf-9555-4e02-b9d3-9eef604476f6Forum:c79f53c3-fa71-4e76-b517-aef042efd7ffDiscussion:5daf4ae6-095a-4ed4-b04e-73aed8be75fd
Forums » Health » Medicare & Insurance » What counts toward the dollar figure to reach the donut hole
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What counts toward the dollar figure to reach the donut hole
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What counts toward the dollar figure to reach the donut hole
posted at January 7, 2012 9:13 AM EST
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Posts: 373
First: October 22, 2011 Last: May 3, 2013 |
I contacted my Medicare Part D insurance carrier to ask about how the money is counted to reach the donut hole. I was reviewing what some prescriptions cost the insurance company which I assume is there negotiated price. Other than one medication that I take, the total cost for the company and the charge for me are equal. In one case the total cost is more than what I pay since in this case I would pay the deductible which would leave the insurance carrier to pay the rest. Now I thought only in the case where the insurance company paid above what I paid them would the money be calculated toward my donut hole limit. Surprising to me, since I was using simple logic, I was told anytime there is coverage under my insurance carrier it would count agains the money accumulated toward the donut hole. I guess when we become senoirs, everyone assumes we cannot think. Why should a payment be counted toward the donut hole when I pay the total cost to the insurance carrier. |
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Re: What counts toward the dollar figure to reach the donut hole
posted at January 8, 2012 9:05 PM EST
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Posts: 2
First: January 8, 2012 Last: March 31, 2012 |
Unfortunately, all covered expenditures count toward the donut-hole threshold, regardless of who paid them. In my opinion, the worst injustice occurs once you faill into the donut hole. Then you have to pay the full negotiated price that the pharmacy charges, plus the monthly enrollment fee. You're still getting some benefit, because the negotiated price of an expensive drug is likely to be less than what the pharmacy would otherwise charge you. What many people don't realize is that there can be a wide difference in prices among the pharmacies where they live. The first step in staying out of the donut hole is to use Medicare's online tool to find the pharmacies with the best prices on the drugs that you regularly take. To give you an example, as reported in one of AARP's publications a few years ago, someone (possibly the town government) did a check on the price of a 30-day supply of 80 mg Simvastatin, a commonly-used generic drug, at pharmacies in their area. I don't remember the exact dollars-and-cents figures but this summary is close enough: Costco: $8 Independent pharmacy: $20 Walmart: $25 CVS: $63 Walgreens: $89 Guess who runs AARP's mail-order pharmacy: Walgreens. In my area, Costco and Target have the best prices. I have an Executive Membership at Costco, so I get all of my prescriptions filled there. Whatever I pay out of my own pocket gets credited to the refund coupon that I receive once a year. However, you don't have to be a Costco member to use their pharmacy and the price to non-members is the same as the member price. It's a state or Federal law that they have to serve everybody. One of the medications that I've taken for 27 years is not prescribed very often anymore and can be hard to get. One pharmacy took as long as five days to fill it, which was unacceptable. When I switched my prescriptions to Costco six or seven years ago, the pharmacist promised me that they would always keep a supply on hand, and if they couldn't get it from their distributor they would get it directly from the manufacturer. They have always been able to fill my prescription. Beyond this, I have found the prescription department at my local Costco (Sterling, Virginia) to be the best that I've ever used. The medication mentioned above is very effective but has serious drug and food interaction issues, so I always read the Patient Advisory Leaflet when I get a new prescription. Whenever I have questions , I don't even bother to call my doctor's office, where I have to go through the nurse, who has to ask the doctor and may not get back to me until the next day. I speak to one of the pharmacists instead, and they always take the time and trouble to research my question and give me a reliable answer. |
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Re: What counts toward the dollar figure to reach the donut hole
posted at January 10, 2012 12:56 PM EST
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Posts: 373
First: October 22, 2011 Last: May 3, 2013 |
As a side note even Costco has a discount program. I like you have found Costco to be less expensive than others, and yes non Costco members may use the pharmacy to obtain their prescriptions. However even here Medicare is being unfare to us, since with your Costco membership you would be entitled to an additional discount but you are excluded since you are on Medicare. |
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Re: What counts toward the dollar figure to reach the donut hole
posted at January 11, 2012 2:25 PM EST
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Posts: 1923
First: November 27, 2011 Last: May 18, 2013 |
In Response to What counts toward the dollar figure to reach the donut hole: I contacted my Medicare Part D insurance carrier to ask about how the money is counted to reach the donut hole. I was reviewing what some prescriptions cost the insurance company which I assume is there negotiated price. Other than one medication that I take, the total cost for the company and the charge for me are equal. In one case the total cost is more than what I pay since in this case I would pay the deductible which would leave the insurance carrier to pay the rest. Now I thought only in the case where the insurance company paid above what I paid them would the money be calculated toward my donut hole limit. Surprising to me, since I was using simple logic, I was told anytime there is coverage under my insurance carrier it would count agains the money accumulated toward the donut hole. I guess when we become senoirs, everyone assumes we cannot think. Why should a payment be counted toward the donut hole when I pay the total cost to the insurance carrier. Posted by JimR45 Jim - There are three (3) parties to Medicare D (1) the government that makes the rules for the overall plan (2) the insurance company which negotiate the pricing of the medications for their various plans (3) YOU - who determines which plan is best for you and your medication list There are three (3) Drug Payment Stages (1) Initial Coverage Stage (2) Coverage Gap Stage (3) Catastrophic Coverage Stage In the Initial Coverage Stage: (1) The insurance plan pays its share of your medication and you pay your share including deductible, if applicable - the total of these two (2) figures determines the cost of the medication for your benefit. (2) Your share of the cost will vary depending on the drug and where you fill your prescription. (3) Your share of the cost of a covered drug will be either a copayment (fixed amount) OR coinsurance (a percentage of the total cost of the drug) - the determination of these two factors depends on the tier classification of the medication. Medicare determines the dollar amount limits for each drug payment stages each year. Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means there’s a temporary limit on what the drug plan will cover for drugs. WHAT IS COVERED FOR THE DRUGS = what the insurance plan pays its share of your medication and you pay your share including deductible, if applicable - You should have a current Medicare Prescription Drug Coverage Booklet from your insurance company that gives all the general Medicare D information for 2012, most likely a formulary list and a list of participating pharmacies for your plan. |
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Re: What counts toward the dollar figure to reach the donut hole
posted at February 6, 2012 11:32 AM EST
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Posts: 373
First: October 22, 2011 Last: May 3, 2013 |
In Response to Re: What counts toward the dollar figure to reach the donut hole: In Response to What counts toward the dollar figure to reach the donut hole : Jim - There are three (3) parties to Medicare D (1) the government that makes the rules for the overall plan (2) the insurance company which negotiate the pricing of the medications for their various plans (3) YOU - who determines which plan is best for you and your medication list There are three (3) Drug Payment Stages (1) Initial Coverage Stage (2) Coverage Gap Stage (3) Catastrophic Coverage Stage In the Initial Coverage Stage: (1) The insurance plan pays its share of your medication and you pay your share including deductible, if applicable - the total of these two (2) figures determines the cost of the medication for your benefit. (2) Your share of the cost will vary depending on the drug and where you fill your prescription. (3) Your share of the cost of a covered drug will be either a copayment (fixed amount) OR coinsurance (a percentage of the total cost of the drug) - the determination of these two factors depends on the tier classification of the medication. Medicare determines the dollar amount limits for each drug payment stages each year. Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means there’s a temporary limit on what the drug plan will cover for drugs. WHAT IS COVERED FOR THE DRUGS = what the insurance plan pays its share of your medication and you pay your share including deductible, if applicable - You should have a current Medicare Prescription Drug Coverage Booklet from your insurance company that gives all the general Medicare D information for 2012, most likely a formulary list and a list of participating pharmacies for your plan. Posted by GailL1 Yes Gail I have the plan booklet and my payment is $9 copay on tier 1 medications. The only prescription I need my medicare is one where there is a large difference between what my former pharmacy charges and my current. In either case I pay only $9 but my insurance would pay around $100 more if I left it where it was before so I moved it to what has now become my major pharmacy since I pay cash for all of the others. There would be no benefit to use my insurance in these other cases. Thanks to Medicare I pay more than I need because I cannot use an added discount from my membership in this store which would allow me to join their prescription club for no additioanal charge. AAARP needs to become involved in this unfairness to us in the medicare plans. |
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Re: Different Prices
posted at February 6, 2012 10:03 PM EST
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Posts: 1923
First: November 27, 2011 Last: May 18, 2013 |
You do understand that you DO NOT have to have Medicare D coverage. Per the Medicare D prescription drug coverage (website): 'Medicare offers prescription drug coverage to everyone with Medicare. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty. To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered." Medicare D is insurance; not just a prescription discount. Note the last sentence: "Each plan can vary in cost and drugs covered" EVERY prescription insurance coverage, be it Medicare, your employer coverage, other health insurance coverage, have different cost associated with a particular medication because these prices have been negotiated by the carrier. If you have a "membership" drug discount when purchasing one of your medications, in order to use the discount , the pharmacy will set the price of the medication and the discount will come off of that price. The membership discount WILL NOT come off of any price you are getting as a participant in an insurance program.
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Re: Different Prices
posted at February 6, 2012 10:22 PM EST
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Posts: 373
First: October 22, 2011 Last: May 3, 2013 |
In Response to Re: Different Prices: You do understand that you DO NOT have to have Medicare D coverage. Per the Medicare D prescription drug coverage (website): 'Medicare offers prescription drug coverage to everyone with Medicare. If you decide not to join a Medicare drug plan when you’re first eligible , and you don’t have other creditable prescription drug coverage , or you don’t get Extra Help , you’ll likely pay a late enrollment penalty . To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. " Medicare D is insurance; not just a prescription discount. Note the last sentence: " Each plan can vary in cost and drugs covered " EVERY prescription insurance coverage, be it Medicare, your employer coverage, other health insurance coverage, have different cost associated with a particular medication because these prices have been negotiated by the carrier. These prices are SET for the particular insurance that you have. NO other discount can be used on these negotiated prices! If you have a "membership" drug discount when purchasing one of your medications, in order to use the discount , the pharmacy will set the price of the medication and the discount will come off of that price. The membership discount WILL NOT come off of any price you are getting as a participant in an insurance program. Posted by GailL1 Gail I have medicare Part D insurance with an RX prescription program which has a copay of $9 for tier one drugs. I have prescriptions where the cost of the prescription is less than the copay. In those cases I do not use Medicare at all but just pay cash where there is no charge and negotiated prices with Medicare has no bearing. Currently I could probably get by with just paying everything myself, but I know about the penalty if I did not apply for the Medicare part D program now and do not want to suffer the consequences in the future. Where there is a copay it about equals the cost of my monthly premium for the Part D prescription cost. |
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Re: Different Prices
posted at February 7, 2012 11:46 AM EST
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Posts: 1923
First: November 27, 2011 Last: May 18, 2013 |
In Response to Re: Different Prices: In Response to Re: Different Prices : Gail I have medicare Part D insurance with an RX prescription program which has a copay of $9 for tier one drugs. I have prescriptions where the cost of the prescription is less than the copay. In those cases I do not use Medicare at all but just pay cash where there is no charge and negotiated prices with Medicare has no bearing. Currently I could probably get by with just paying everything myself, but I know about the penalty if I did not apply for the Medicare part D program now and do not want to suffer the consequences in the future. Where there is a copay it about equals the cost of my monthly premium for the Part D prescription cost. Posted by JimR45 If you researched all your medication cost on the various Med D plans in your area (on the Medicare D website) and you found that what you are now doing (how you are paying and getting your medications) is the best for your wallet, then it seems it is best for you to do it this way. However, I still don't understand what "unfairness" you want AARP to focus on with the Medicare D program. |
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Re: What counts toward the dollar figure to reach the donut hole
posted at February 8, 2012 3:24 PM EST
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Posts: 373
First: October 22, 2011 Last: May 3, 2013 |
The issue is that Medicare stops me from using a benefit at the store where the price of prescriptions below my deductible could be further discounted by applying to their discount club which would be free to me since I am already a member. I cannot apply for this added benefit since I am on medicare. My $8 charge which I pay myself would be discounted even more if I was allowed to join this club. SIDE NOTE: My other thread speaks more on this topic. I started this thread before I found out that my supplemental insurance did not correctly identify charges for me under medicare. |
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Re: What counts toward the dollar figure to reach the donut hole
posted at February 8, 2012 3:28 PM EST
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Posts: 373
First: October 22, 2011 Last: May 3, 2013 |
In Response to Re: What counts toward the dollar figure to reach the donut hole: Unfortunately, all covered expenditures count toward the donut-hole threshold, regardless of who paid them. In my opinion, the worst injustice occurs once you faill into the donut hole. Then you have to pay the full negotiated price that the pharmacy charges, plus the monthly enrollment fee. You're still getting some benefit, because the negotiated price of an expensive drug is likely to be less than what the pharmacy would otherwise charge you. What many people don't realize is that there can be a wide difference in prices among the pharmacies where they live. The first step in staying out of the donut hole is to use Medicare's online tool to find the pharmacies with the best prices on the drugs that you regularly take. To give you an example, as reported in one of AARP's publications a few years ago, someone (possibly the town government) did a check on the price of a 30-day supply of 80 mg Simvastatin, a commonly-used generic drug, at pharmacies in their area. I don't remember the exact dollars-and-cents figures but this summary is close enough: Costco: $8 Independent pharmacy: $20 Walmart: $25 CVS: $63 Walgreens: $89 Guess who runs AARP's mail-order pharmacy: Walgreens. In my area, Costco and Target have the best prices. I have an Executive Membership at Costco, so I get all of my prescriptions filled there. Whatever I pay out of my own pocket gets credited to the refund coupon that I receive once a year. However, you don't have to be a Costco member to use their pharmacy and the price to non-members is the same as the member price. It's a state or Federal law that they have to serve everybody. One of the medications that I've taken for 27 years is not prescribed very often anymore and can be hard to get. One pharmacy took as long as five days to fill it, which was unacceptable. When I switched my prescriptions to Costco six or seven years ago, the pharmacist promised me that they would always keep a supply on hand, and if they couldn't get it from their distributor they would get it directly from the manufacturer. They have always been able to fill my prescription. Beyond this, I have found the prescription department at my local Costco (Sterling, Virginia) to be the best that I've ever used. The medication mentioned above is very effective but has serious drug and food interaction issues, so I always read the Patient Advisory Leaflet when I get a new prescription. Whenever I have questions , I don't even bother to call my doctor's office, where I have to go through the nurse, who has to ask the doctor and may not get back to me until the next day. I speak to one of the pharmacists instead, and they always take the time and trouble to research my question and give me a reliable answer. Posted by rsimanski "In my area, Costco and Target have the best prices. I have an Executive Membership at Costco, so I get all of my prescriptions filled there. Whatever I pay out of my own pocket gets credited to the refund coupon that I receive once a year." Are you aware that with your Costco membership they have a discount club available which is free to those who already have a Costco membership? Only problem is that since you are on Medicare, you cannot apply for it. You can thank our government for that. I was told the restriction was from Medicare not the pharmacy. |
Forums » Health » Medicare & Insurance » What counts toward the dollar figure to reach the donut hole
