Coverage Gap

The coverage gap or “Doughnut Hole” is something seniors were warned about in selecting their coverage plan, but many did not understand until they recently began to find themselves faced with a huge drug bill.


Insult Added to Injury

Although the plan has reportedly helped millions of seniors meet ends with much lower drug bills than they had without any drug coverage, suddenly finding themselves having to foot the entire bill is a shock. This is in addition to the insult of having to continue to pay $24 per month for the premium.

Coverage Gap Hits at $2250

Medicare’s Part D covers the bulk of drug costs until the patient and Medicare have paid out a combined total of $2250 per year. Once the beneficiary has met that amount, they have to pay the entire drug cost until they have paid out-of-pocket $3600. At that point Medicare steps back in and covers 95% of the drug costs for rest of the year.

January 1 Coverage Starts Again

On January 1, the slate is clean and the $2,250 coverage starts over again. The “doughnut hole” coverage gap resumes again when the $2250 is reached and the patient is responsible for $3600 again until any help is available once from Medicare, or January 1, whichever comes first. This vicious cycle was bitterly contested in Congress and defeated in passage of the bill. It is being highly criticized in 2014 election issues particularly by Democrats.

Continue Using Medicare Part D Drug Card

Seniors caught in the coverage gap need to continue to use their Medicare drug card so that they get the lower negotiated costs for their drugs. They can also now apply to state run drug-assistance plans as well as those run by the pharmaceutical companies. They can call Medicare for information and help at (800)633-4227.

Generic Drugs and Mail-Order Drug Plans

Using generic drugs and ordering 90-day supplies of medications from mail-order pharmacies have helped some seniors avoid the coverage gap, and will help others delay reaching the gap.

Medicare Open Enrollment Begins Nov. 15

Seniors can opt to change their coverage next year during Open Enrollment which begins November 15. With perhaps a better understanding of how the program works, seniors can more carefully research plans which will better fit their needs. Plans that have negotiated lower costs for the specific medications the beneficiary takes will be the most beneficial. For married couples, this may mean a different plan for each spouse.

Research Your Plan Carefully

Medicare through its website offers comprehensive information and comparison of plans which is non-biased. Start your research here. Ombudsmen and Senior citizen centers offer counselling and assistance in selecting plans without vendor biases.

Buyer Beware of Advertising

The insurance companies sponsoring the plans are beginning to once again heavily market their products in campaigns on television and in print media as Open Enrollment approaches. Your pharmacist can also help you to compare plans and decide which one best fits your needs. Do your homework and select a plan based on the drugs YOU take.