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Medicare Part D has been a blessing for so many senior citizens who are on a fixed income and have a limited budget to spend on prescription medications. However, for those patients who have a lifelong illness, the Medicare Part D gap in coverage can be a startling realization.

At the beginning of the second quarter of the year you hear a lot of talk regarding the coverage gap or donut hole. What is it, why is it there, and how does it work? Prescriptions help so many patients but only if they can get them!

The coverage gap (donut hole) was created to
decrease the cost of Medicare’s Part D coverage. Each year, a limit for Part D is determined. In 2007, the annual limit was $2400. In 2008, the annual limit was increased to $2510. In 2009 the amount is $2,700. The limit is calculated on the total costs of the prescription medications that you receive. This includes what the insurance company pays and your co-pays.

For example, if a medication is $550 and the insurance company pays $500 and the patient pays $50, the amount that goes towards the annual limit is the enire $550

While in the donut hole, you must pay for all of your prescription drugs out-of-pocket. There are several Medicare part D plans that offer coverage for generics when you are in the coverage gap. This really isn’t that great of a benefit because these Part D plans seem to cost more per month than most generic drugs actually cost[/spin. For [spin]some people it could be worth it to have coverage for generics, everyone’s situation varies.

For Medicare patients with chronic health conditions which often require high priced medicine for treatment, the donut hole or coverage gap can be reached in a matter of months get to the donut hole as soon as February. The point for the coverage gap was to encourage patients to purchase less expensive pharmaceuticals when possible. That is okay for those patients who have that option but it punishes those who must use high priced medications because nothing else works. For instance, for patients with rheumatoid arthritis whose health condition can only be successfully controlled by Enbrel, they can go into the coverage gap within 2 or 3 months. Then, they must pay for their medications at full price for the remaining months until the catastrophic coverage portion of Part D kicks in, or suffer the potentially disabling consequences of coming off their medications.

The price of Enbrel is about $1500 per month. There are many seniors who are not able to pay for that.

Some patients will be able to take advantage of Prescription Assistance Programs due to their lower income. Going directly to the pharmaceutical company can be very helpful in obtaining low or no cost prescription medicine. Contact the company and ask about their Prescription Assistance Program. Most all drug companies offer such programs, which enable consumers to receive prescriptions they need at a price they can afford (often for free). A lengthy application co-signed by your healthcare provider is typically necessary for entry into the program.

Patient Assistance Programs run by drug manufacturers have been in existence for over 20 years. These programs are designed to help eligible individuals who can’t afford their medicine due to limited income or other financial hardships. Drug companies did not want their low income customers to be forced to make a choice between paying for life saving drugs or for paying for rent or groceries. As a result, patient assistance programs came into being as part of the company’s philanthropic efforts. Until relatively recently, very few people knew about these programs or could follow the complicated application process that was required for participation. Often times multiple applications had to be filed

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