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Tips for staying out of the Medicare prescription plan ‘donut hole'

Posted at 11:05 AM, Dec 11, 2014

Most Medicare prescription drug plans have a coverage gap, often called “the donut hole." The donut hole refers to a temporary limit on what a plan will cover for drugs, meaning the patient pays a larger portion of drug costs during this period.

In 2015, once a person has spent $2,960 (including the deductible and co-pay) on covered drugs, he falls into the donut hole. The donut hole ends when a total of $4,700 is spent in 2015.

Once there, the person is responsible for 45 percent of the cost of a brand-name prescriptions, and 65 percent of generic prescriptions. While not everyone will reach the donut hole, it commonly affects people with chronic diseases such as Diabetes, Alzheimer’s, osteoporosis and more.

Talk to a pharmacist before a trip to the doctor
Pharmacists are geriatric specialists and are extremely knowledgeable about the prescription needs of older adults.
Speaking with a pharmacist before the doctor could be a financial benefit — they can recommend asking the doctor about certain prescription drugs for specific needs that are just as effective and more affordable.

They also may take the time to discuss a patient's current health and may find medications that may no longer need taken.

Spending less on prescriptions means staying out of the donut hole longer.

Consider switching to the generic version of a drug
Throughout 2014, several of the world’s best-selling brand-name drugs will lose their patent, allowing generic versions to be sold at a much more affordable cost. Generic versions of top-selling drugs for COPD, Alzehimer’s, MS, Glaucoma, high blood pressure and more are all set to become available in 2015.

Expiring patents include: Tarka, Abilify, Namenda, Combivent and Avalide. among others. Generic versions contain the same active ingredients and are chemically equivalent to the brand-name drugs, but they typically cost 20 to 80 percent less.

Ask for the cash price
Especially with generic prescriptions, paying with cash could be cheaper than using Medicare coverage. For example, a person may have a co-pay of $12, but be able to get a 3-month supply of certain drugs for $10 if he pays in cash. In paying with cash, there is no use of Medicare coverage, and therefore no contribution to the $2,960 current spending limit before falling into the donut hole.

Stick with one pharmacist
Compare the costs of all medications as a whole and choose the pharmacy with the best overall price. By getting all medications from the same place, a patient is reducing the risk of harmful drug interactions and forming a relationship with a pharmacist, so they are better able to understand your health needs.

The non-profit difference
A non-profit pharmacy is typically able to provide several cost-saving measures like reduced markup on prescriptions for clients.

Emily Glaser writes about the diverse wellness needs of older adults for Your Time, a Community First Solutions publication for people age 50 and older. Community First Solutions is based in Hamilton, Ohio.