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Medicare Part D has been a God-send for so many seniors who are on a fixed income and have a limited budget to spend on prescription medications. However, for those seniors who have a lasting illness, the Medicare Part D coverage gap can be a real shock. By the end of the second quarter of the year you hear a lot of talk regarding the donut hole or coverage gap. How does it work, what is it, and why is it there? How does it provide prescription drug help?

The coverage gap (donut hole) was created to decrease the cost of Medicare’s Part D coverage. The yearly limit for Part D is determined each year. $2400 was the 2007 yearly limit.  $2510 is what the yearly limit was increased to in 2008. $2700 is the amount in 2009. determination of the limit is based on the total cost of the drugs that you receive. This includes what the insurance company pays and your co-pays. For instance, if a drug is $550 and the patient pays $50 and the insurance company pays $500, the amount that is applied to the annual amount is the full $550

When you are in the donut hole or coverage gap, you must pay for the cost all of your prescription drugs. Many Medicare Part D plans offer generic drug coverage when you are in the donut hole or coverage gap. The cost of most generic drugs is so small that the benefit of having them covered by a plan isn’t that much of a benefit. It might be worth it to have coverage for generic drugs for some patients because everyone’s situation is different.

In just a few months a Part D patient with chronic conditions can be in the donut hole as a result of their high priced prescription medication. Reaching the donut hole as soon as February is not uncommon. Steering patients to use cheaper medications when possible is the reason for the coverage gap. Because nothing else works it punishes those patients who must use costly medication.

For example, for people with rheumatoid arthritis whose condition can only be successfully controlled by Enbrel, they can fall into the donut hole or coverage gap within 2 or 3 months. The option at this point is to pay for the prescription at full price for several months until the catastrophic coverage portion kicks in or suffer the potentially disabling consequences of stopping their medication. Enbrel costs approximately $1500 per month. Very few seniors can actually afford that.

Patient assistance programs will help those who qualify.

One of the best ways to get low cost or free prescriptions is to talk to the drug manufacturer. Contact the company and ask about their Prescription Assistance Program.  Most all pharmaceutical companies offer these programs, which enable consumers to receive prescription medicine they need at a price they can afford (often for free).  You and your doctor will need to complete an application. Patient Assistance Programs run by pharmaceutical companies have been in existence for over 16 years. These programs are designed to help eligible individuals who cannot afford their prescriptions due to limited income or other financial hardships.  Pharmaceutical 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 patients knew about these programs or could follow the complicated application process that was required for participation. Often times several applications had to be filed. Please do your research and get the help with prescriptions that you need.