In 2006, the federal Medicare program enacted a subsidy program for seniors to receive financial help in purchasing prescription drugs.
The program, Medicare Part D, covers 25 percent of prescription drug costs-to a point. Once the plan has covered $2,830 of costs, participants must pay the full amount of their drugs out-of-pocket, until they have paid up to the total catastrophic coverage limit, excluding premiums. That amount has increased yearly, and in 2010 it was $4,550.
“I usually hit the donut hole in October or November,” said Lucille Hilton, 74, referring to the out-of-pocket period by its common nickname. She uses Plan D for medication to treat her diabetes.
“I take shots and that’s when it goes way high,” she said. “Right now I’m paying $79 (to fill a prescription).”
The gap in coverage can hit seniors, who often have greater medical demands and a fixed income, the hardest. On top of her prescription payments, Hilton recently had to go into debt to purchase a hearing aid and dental realignment, she said. She cannot afford medication to regulate her blood pressure because the particular pill is only available in a more expensive brand name form.
This year, the federal government reported it would cut 4 million $250 checks for Part D patients in the donut hole, using money granted from the Patient Protection and Affordable Care Act. The checks, which go to patients that aren’t already receiving Medicare Extra Help, are the first step in Congress’ proposed efforts to fill the coverage gap by 2020.
But information about the first checks haven’t reached every senior—Hilton said she hadn’t heard about the program to fill the donut hole.
On the other end of the spectrum from Hilton is Shirley Spietz, who has never fallen into the donut hole, but has brand name-only medication prescriptions that aren’t covered by Medicare Part D.
“One of my prescriptions costs $6 and the other costs $250,” she said. “I have to pay for the other myself.”
Martin Hubbard, the owner and pharmacist for Nicholson’s Sumner Pharmacy, doesn’t like the way the donut hole is implemented, he said.
“Of course we don’t like it,” he said. “It takes a lot of time to explain and it’s a difficult concept. It should have a defined period throughout the year.”
A computer database at the pharmacy keeps track of who is currently covered by Part D and who is in the donut hole. Patients who are in the donut hole handle the extra cost in different ways, Hubbard said.
“We have a lot of people who pay cash for inexpensive medications and spread their benefits throughout the year,” he said. “Or, they’ll purchase double-strength versions of their pills and cut them in half. Or they’ll find out what other medications are in that category of what they need, but that are maybe cheaper. It’s a very time- consuming thing, but we’re able to give that advice.”
Part D does cover some brand names, but the system overall is heavily weighted toward generics, Hubbard said.
The next step in federal help for minimizing the donut hole will be specifically targeted at brand -name expense. In 2011, patients who reach the coverage gap will receive a 50 percent discount on brand- name prescriptions, plus a $250 check.