The gap in Medicare Part D coverage, aka "the donut hole," may be a problem for many of your older patients, starting right about now.
Many seniors with a Medicare Part D prescription drug plan will experience a lapse in coverage about this time of year-- the dreaded coverage gap, often referred to as the donut hole. While individuals taking solely inexpensive generics may never reach the coverage gap, patients with as few as one or two branded medications may quickly top the $3,750 threshold where the dropoff in coverage begins. Patients who qualify for Extra Help under Medicare are not subject to the donut hole.
In the coverage gap, patients pay 35% of the plan’s cost plus the dispensing fee as a copayment. This copay combined with a 50% manufacturer discount on brands during the coverage gap count as out-of-pocket expenses and toward catastrophic coverage. The formula for generics is similar; for 2018 patients pay 44% of the plan’s cost plus any dispensing fee which counts toward out-of-pocket expenses.
Despite drug coverage during the donut hole steadily improving over the last several years (the coverage gap is due to disappear in 2020), patients on branded medications can be left bewildered when copays climb from $47 to $147 seemingly overnight. Price is a major factor in medication nonadherence that may lead to additional office visits and possible hospitalizations.
Consult with your patient’s pharmacist to determine the most cost-effective substitute, if appropriate, for an expensive medication during the coverage gap. Unfortunately, Medicare Part D enrollees are prohibited from using manufacturer copay cards under the anti-kickback statute. Encourage patients who cannot afford their medications to apply for Extra Help by contacting their local Medicaid office or their State Health Insurance Assistance Program.