Have you reached the donut hole in Medicare coverage?
If so, you know it begins when you and your drug plan have spent a total of $3,310 on your medications. Then, you have to pay a higher share of medication costs until you reach the other side of the donut hole.
If you haven’t yet reached that point, there are ways Medicare advises people to slow their descent into the donut hole by keeping overall costs lower.
• Ask your doctor to prescribe generic drugs if they are appropriate in your situation.
• Find out if your local pharmacies offer your drugs at a reduced cost (more about this later).
• Take advantage of mail-order programs which are often (not always) less costly, and may allow you to purchase long-term drugs in 90-day supplies, for about the same copay as a smaller supply.
• If your Medicare prescription drug plan or Medicare Advantage Prescription Drug plan has both preferred and non-preferred pharmacies in its network – your copayments will be lower if you fill your covered prescriptions at a preferred pharmacy.
• Present your member card if you use a Medicare Advantage Prescription Drug plan or Medicare prescription drug plan, to get discounted rates, and to be sure the amount you pay counts toward your deductible.
Suppose you’ve reached the donut hole?
Many of the same tips apply when you’re trying to slow your descent to the donut hole and while you’re in it, paying out of pocket.
Ask your druggist about discount programs. Some don’t work in coordination with Medicare, but many do. Depending on the drug, it might be cheaper to actually bypass your insurance (especially private insurance) altogether. Your insurer may not tell you this, because in some cases, they are profiting by your lack of knowledge.
Example: For years I paid $20 for a 30-day supply of a maintenance drug, through my private insurer. That meant schlepping into the pharmacy every single month. When I asked if I could get a 90-day supply the pharmacy clerk told me my insurance wouldn’t allow it.
Then I found out why.
One day the pharmacist himself waited on me, and asked, “Why don’t you bypass the insurance and pay cash for this? You’ll save money, and you could get a 90-day supply.”
Thanks to his good advice, instead of paying $20 for a 30-day supply, I now pay $19 for a 90-day supply. It’s definitely worth asking the pharmacist. No wonder my insurance didn’t tell me. Could this be happening to you?
There is some good news, brought by the Affordable Care Act. Beginning in 2015, the coverage gap of the donut hole began to close a little each year. Here’s a chart from Medicare.
• In 2016, you’ll pay 45% for brand-name drugs and 58% for generic drugs.
• In 2017, you’ll pay 40% for brand-name drugs and 51% for generic drugs.
More about drugstore programs
Many drugstore programs have membership fees, so be sure to find out. Kmart is $10 per person or $15 for a household, so factor this into the total cost when deciding where to buy. Sam’s Club and Costco generally offer the very best prices.
Kmart sells many drugs for only $3 per prescription. And in 14 states, Walmart offers a long, long list of generic drugs for $4 each. See the list at this website.
Unless you ask, this information may not be shared with you. Why? Plans vary, and some won’t inform you of your options unless you are on Medicare.
Generic or brand name
Currently about 75 percent of all brand name drugs have generic equivalents, and using a generic could save you as much as 90%, so it’s worth a try. Ask your doctor if he or she will prescribe a generic if there is one.
If there isn’t, ask about less-expensive alternatives. If there’s no generic or your doctor insists on the brand name, check the website of the drug manufacturer. They may offer coupons, or “copay cards.”
Or do an Internet search by typing in the name of the drug and “coupon.” Not every pharmacy will accept every coupon, but most will and they can save you up to 50 percent.
Also ask your pharmacist if they offer a discount-drug program and compare costs with your insurance plan. You can also find free drug discount cards online at sites like NeedyMeds.org, which can be used at most U.S. pharmacies.
If the pharmacy clerk doesn’t seem to know what to do when you present a discount card, you may need to ask to speak to the pharmacist. My mother’s doctor gave her cards and assured her the pharmacy would take them, but they didn’t.
It turned out the clerk was just unfamiliar with the process. It’s worth a try to ask the pharmacist directly.
Drug cost assistance
Medicare.gov lists various programs where you can get assistance with prescription costs. Here are several:
• “Extra Help.” If you are single and earn no more than $17,820 or married and earn no more than $24,030 you may qualify for Medicare’s “Extra Help” program. If so, you should pay a maximum of $2.95 for generic drugs and a maximum of $7.40 for brand name drugs.
• State plan. Don’t qualify for Extra Help? See if your state has a SHIP plan, state health insurance assistance program.
• Needymeds. Needymeds is a place where you may find discounts, and while you’re there, look around. There’s a lot of good stuff there.
• BenefitsCheckUp.org is another site to find possible discounts if you have limited income.
• Shop by mail. Many plans offer discounts for by -mail orders, but not always. Before you sign up, get a list of the medications you want and the dosage and check the prices.
• Apply for a price break. Medicare.gov, lists pharmaceutical assistance plans that make your medication more affordable.
• Find a better drug plan. Compare costs of Medicare Part D and Medicare Advantage plans at Medicare.gov. If you find a better one, you can switch during open enrollment which begins on October 15, 2016. But before you switch, verify that the new plan does cover your medications and that the price really is better.
Many pills can be prescribed for a double dosage of your medicine, and then split in half. The cost is usually the same as for the lower dosage. But you’ll need to get your doctor to prescribe the higher dosage, and tell him or her why you want it. Not all pills can be split, but of course your doctor will know this.
If you have a medication that is splittable, you end up getting twice as much medication for virtually the same price. Buy yourself a pill splitter at the drug store for easy, accurate splitting. And resist the temptation to split several pills in advance. That can lead to rapid deterioration, so only split enough for a day or two, or as your doctor advises.
Teresa Ambord is a former accountant, a longtime freelance writer and a frequent contributor to Good Age. Send comments or questions to [email protected].