What Do Plans Do To Address The “Donut Hole”?

As part of Medicare Part D, coverage for prescription drugs varies based on the total amount of money by participant. Participants have one amount of coverage until their costs (plan plus participant) reached $2,250 (2006 #s). Then, they don’t receive any coverage (i.e., pay full price) until their out-of-pocket costs reach $3,600. This gap is lovingly referred to as the donut hole.

Numerous studies have shown that adherence suffers when patients have to pay the full cost of their medications during this time period.

I haven’t seen a lot of programs focused on educating consumers about this (i.e., you’re about to reach the donut hole…here are some actions you can take). Consumers can save money (or delay hitting the donut hole) by using generic medications and mail order (among other strategies). There are also PAP (patient assistance programs) or other things that they can look into. [More info from the U.S. Centers for Medicare and Medicaid Services on this.]

In a survey by Medco Health Solutions, they found that 49% of the seniors polled that were enrolled in a Medicare Part D plan were worried about how to avoid the donut hole.

  • 60% of them had done something to avoid reaching the donut hole
    • 76% using generic medications
    • 39% asking for free samples
    • 27% using mail order

In the Medco survey, seniors estimated that using mail order saved them $540 a year and 19% estimated they saved at least $1,000 annually. [They provide information at http://www.medcomedicare.com.]

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