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Trying to Avoid the Doughnut Hole

Q. It was hard for me to afford my prescription drugs this year after I fell into the Part D doughnut hole. Is there anything I can do to avoid it next year?

Maybe—and it’s well worth exploring ways to try to steer clear of the doughnut hole (officially called the coverage gap) or stave it off until later in the year. The key strategy is to do as much as you can to stretch the initial coverage you receive from your Part D plan at the beginning of the year.

In 2010 you get a maximum of $2,830 worth of initial coverage. This sounds like a lot, but it actually means the total cost of your drugs—what you and your plan pay for them—and it can be used up very quickly if you take multiple or expensive drugs. Once it’s gone, you’re in the doughnut hole, unless you have additional coverage (for example, from an employer plan that works with Part D or veterans’ drug benefits).

Here are some ways you might be able to make your initial coverage last longer:

* Choose lower-cost drugs if possible: Ask your doctor if any of your medications has a lower-cost alternative that would work just as well for your health condition. This could be a generic—an inexpensive copy of the brand-name drug you’ve been prescribed—or an older brand-name drug that’s been on the market longer. If you have this option, using those alternative drugs are likely to lower your copayments significantly, in addition to stretching your initial coverage. It’s the best way to avoid or postpone the sticker shock of the doughnut hole.

* Check out Extra Help: If your income is limited, or has been substantially reduced recently, check to see whether you qualify for Part D’s Extra Help program, as explained here. If eligible, you’ll receive continuous drug coverage throughout the year—there’s no doughnut hole for anyone receiving this valuable assistance.

* Compare Part D plans during open enrollment: Part D plans negotiate prices with the manufacturers, and some get better discounts than others. So if, for example, your drugs cost $500 a month at full price under one plan and $370 under another, you’d save $130 a month in the latter plan and it would take longer to hit your $2,830 initial coverage limit. Remember that it’s the drugs’ full price that counts toward that limit, not just your copays. (You can see the price variation by using the Prescription Drug Plan Finder comparison tool on Medicare’s website. For a consumer guide on navigating the plan finder, click here.)

* Consider mail order: Many, though not all, Part D plans charge lower copays for drugs bought in 90-day supplies through mail order. Their full prices are often less for mail order, too. So this may be another way to stretch those initial coverage dollars if you take some meds regularly throughout the year.

* Check up on your medications: Do you really need all the drugs you take? When people see a variety of doctors for different ailments, they can easily end up taking too many medications without realizing it. Experts recommend that if you take more than five medications (over-the-counter ones as well as prescription drugs) or more than 12 doses a day in total, you should ask a doctor or pharmacist to review them all. Ask if each drug is still necessary for your health, is appropriate for your age and can be safely taken with all the others. If your doctor finds you can cut down on your meds without affecting your condition, the reduction benefits your health as well as your pocketbook.

* Consider lifestyle changes: Ask your doctor if any changes you can make—better diet, more exercise, no smoking—could allow you eventually to reduce the drugs you’re now taking.

Patricia Barry is a senior editor at the AARP Bulletin.

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