Closing the Medicare Prescription Drug Doughnut Hole

It seems like a bad dream: Your prescription drug coverage stops just when you need it the most. But sadly, it’s been a reality for millions of people with Medicare. When the Medicare prescription drug program (Part D) was created in 2003, it included a large gap in coverage that’s known as the “doughnut hole.” After beneficiaries reached an initial limit of total drug expenses ($2,840 in 2011), they had no prescription drug coverage until they got to the other side of the doughnut hole – by spending $3,600 more out of their own pockets – and reached the catastrophic limit for the year.

The doughnut hole meant that nearly 4 million beneficiaries with significant prescription drug costs – the people who need help the most – had to pay the full cost for their medications for months at a time. Many had to choose between buying their medications and buying groceries. Others resorted to skipping doses or splitting pills. What’s more, the problem was going to get worse: The gap was expected to grow to more than $6,000 by the year 2020.

But things are getting better. Under the Affordable Care Act (the new health care law), the nearly 4 million Medicare beneficiaries who fell into the doughnut hole in 2010 each received a $250 check to help with the cost of their prescription drugs. Starting this year, the help is more significant. Beneficiaries in the doughnut hole receive a 50 percent discount when they purchase brand-name drugs. They will also receive discounts on generic drugs. These discounts will increase over the coming years until 2020, when the doughnut hole will be completely closed. In 2020, in other words, beneficiaries who otherwise would have had to pay up to $6,000 out of their own pockets for prescriptions will, thanks to the new health care law, only have to manage the copayments.

Closing the doughnut hole should help people in two ways. First, it will save them money. The agency that runs Medicare reports that, as of the end of February, nearly 11,000 beneficiaries have already used the discount program to move through the doughnut hole. They saved an average of $1,775 per person. As the year goes on, more and more people with substantial prescription drug needs should see similar savings. That’s money that can be used to buy groceries, fix up your home, or even have a little fun. And the savings will increase in future years.

Secondly, closing the doughnut hole should improve people’s health. Prescription drugs are an increasingly vital part of staying healthy. Sticking to a prescription drug regimen your doctor orders can keep chronic conditions like diabetes and high blood pressure manageable. But when people can’t afford their drugs, they skip doses or stop taking their prescriptions altogether. This leads to disruptive and expensive complications and hospitalizations down the road. Making prescription drugs more affordable stops this cycle before it begins. And it gives you more control over your health care.

To learn more about how the Medicare Part D drug discount program works and what it means for you, visit the Medicare section of the Families USA website at www.familiesusa.org. You can also get information about Part D and the new discount program at www.medicare.gov or by calling 1-800-MEDICARE.

Even with the new discount program, some people with limited income and resources may need more help paying for their medications. They may be eligible for the Extra Help program. Visit the Social Security Administration website, www.ssa.gov/prescriptionhelp, or call 1-800-MEDICARE to find out more. You can also check to see if your state offers a prescription drug assistance program that can provide additional help with prescription drug costs.

The Medicare doughnut hole never made any sense as a matter of good health care. Now, thanks to the new health care law, you can wake up from this bad dream and find that the doughnut hole has been filled in.

ROB POLLACK, EXECUTIVE DIRECTOR, FAMILIES USA

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