Medicare Part D Health Article

Medicare Part D:  Paula Duffy, Test Case

Millions of Americans have taken advantage of the Medicare Part D prescription coverage program, thinking that if they pay their monthly premiums, their prescriptions will be covered.  The donut hole is a coverage gap between a Part D Plan's initial coverage amount and $3,850 that may affect some seniors' wallets, depending on how much they spend on medications each year.

The following scenario demonstrates how one fictional senior would find herself in the donut hole and some cost–saving suggestions for her medications. 

Ms. Duffy is 73 years old with high blood pressure, high cholesterol, asthma, depression, anxiety and osteoporosis and takes these medications. (Costs shown are for a 90 day supply.)

High blood pressure:

• Spironolactone – $29.97
• Hydrochlorothiazide – $8.99

High cholesterol:

• Questran – $630.67
• Lovastatin – $98.99

Asthma:

• Azmacort inhaler – $131.24
• Proventil – $39.99
• Singulair – $301.50

Depression/anxiety:

• Lexapro – $222.19

Osteoporosis:

• Fosamax  Plus D – $253.73

Total annual costs $6,869.08

Cost–saving suggestions:

• A combined form of Spironolactone and Hydrochlorothiazide is available for $20.99 for a 90 day supply
• Switching to generic equivalent of Questran (cholestyramine) and switching to cans instead of individual packets drops the cost to $104.56

New annual cost $4,692.76 Savings $2,176.32

Q: Is Ms.Duffy in the dreaded donut hole (coverage gap)?

A: Yes.  When she reached $2250 spent by Medicare and her own out–of–pocket expenses for covered medications she entered the donut hole.

Q: Can Ms. Duffy save any more money?

A: The big ticket items are the Singulair and the Fosamax. Ms. Duffy speaks to her provider about her financial hardships and get the following advice:

• Singulair is a leukotirene inhibitor which an online drugstore sells for $170
• Fosamax: generic equivalent alendronate is available at an online drugstore for $102
• Lexapro can be found online for $104

Now we have Ms. Duffy's annual costs down to $3087.08.

Unfortunately, like many seniors, Ms. Duffy would still find herself in the donut hole, paying over $800 out of her own pocket and facing heartbreaking decisions like whether to pay for prescriptions, food or her mortgage payment.

It pays to shop around and talk to your provider about alternatives. Work with your provider to see what alternatives are available to you.

How does this affect me?

The take-aways from our test case scenario are true for every Medicare eligible person.

• Be aware of the date you will become Medicare eligible and don't miss the opportunity to sign up for Medicare Part D early.  It is a voluntary program that will save you money on prescriptions throughout your lifetime.
• Remember this program is in its beginning stages and it may improve over time, especially as more people become Medicare eligible.  The first Baby Boomer filed for Social Security benefits in 2007.
• If you have prescription benefits through another insurance plan, talk to your benefits administrator before enrolling in Medicare Part D to avoid jeopardizing the benefits you already have in place, which may be better.
• List all of the medications you currently take.
• Review with your physician whether or not you can substitute a less expensive generic medication.
• Review with your physician whether or not a less expensive medication in the same class of drugs will work for you.
• Find out what insurance plans are offered in your area, using your zip code.
• Review carefully the formulary of each plan to see if the medications you are taking are covered.
• Review the formulary of each plan to find out what Tier of coverage the medications you are taking fall into.
• Compare the costs of medications under each plan.
• Determine in which month of the year you will reach the donut hole or coverage gap.
• Determine how many months you will remain in the donut hole.  Three months?  The rest of the year?  Can you afford it?
• Compare the monthly premiums of each plan.
• Determine if, by paying for a more expensive monthly program with gap coverage, you will save money.
• Plan to repeat this process every November.  Pay attention to the Plan you choose:
• Did they increase the prices of medications?
• Did they increase your co-pay?
• Did they increase your premiums?
• Did they change the Formulary Tier for your medications?
• If you answer YES to any ONE of these questions it may  PAY TO SWITCH plans.
• If there is one message we can leave you with :-
• Evaluate your current plan carefully
• It may PAY TO SWITCH

You can use Healthline's Part D Plan Selector to find which plan might be right for you. Click here to learn more.