How To Avoid The Medicare Donut Hole

Anyone who has Medicare and takes lots of drugs or a few very expensive ones (or who has an older relative who does) knows about the dreaded “donut hole”—the gap in coverage that happens each year if you have to spend a lot of money on prescriptions. If you’re above the poverty level but don’t have good gap insurance, it can be financially devastating. The New York Times notes that for a quarter of at-risk patients, planning ahead with generics may help you skirt the donut hole altogether. The big stumbling block is that you have to be prepared to discuss your personal finances with your doctor.

When patients hit the donut hole, all sorts of bad things can happen. First, switching to generics introduces the risk of new or worse side effects. But some patients—according to a recent AARP study, about 15%—stop taking their prescriptions altogether, or else they rack up huge credit card debts to continue paying for the drugs.

Sometimes a patient can score free samples of the drugs he’s taking, but unfortunately the value of these “free” drugs won’t count toward his annual overall expenditure, so the patient remains stuck in the donut hole, and has to start paying against it again once the Free Drug Train leaves the station.

The New York Times quotes one study that says 23% of patients could avoid the donut hole if they started with generics at the beginning of the year. But to do this, you have to talk to your doctor about your personal financial situation, which can be difficult. One study found that

four of five [patients] wanted doctors to discuss medication costs, but fewer than one in five doctors did. One in three patients in the study who cut back on their drugs because of cost said they had never asked their doctor for help in reducing expenses.

“Usually I’m a little blind to it if they’re in the doughnut hole,” Dr. Epperly said, “mainly because they’re proud people, and they feel their obligation isn’t to share that with the doctor.”

Otherwise, the Times suggests that patients visit the Medicare plan comparison service to see if there’s a plan that meets their needs. However, for patients who can “rely solely on generic drugs,

the cheapest approach in the short run might be to forgo Part D insurance altogether. Instead, they could simply shop at discount retailers like Wal-Mart, Costco and Target whose pharmacies offer low-cost generics for as little as $4 for a monthly prescription.

We’re not sure what they mean by “in the short run”—that sounds a little ominous when you’re giving advice to seniors—but if it keeps you out of the donut hole, go for it.

“Strategies to Avoid Medicare’s Big Hole” [New York Times]
“There Are Alternatives: Insuring to Bridge the Gap or Opting Out” [New York Times]

“Find & Compare Plans that Cover Drugs” [Medicare]
“Seniors in Part D donut hole unlikely to have gap coverage” [Managed Healthcare Executive]
“5 Ways to Lower Your Costs During the Coverage Gap” [Medicare]
(Photo: Getty)