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Five Tips for Avoiding the Medicare Part D Coverage Gap

Prescription drug coverage is important for senior citizens, many of whom rely on more than one medication to stay healthy. Medicare beneficiaries may sign up for prescription drug coverage through a separate Part D prescription drug plan or through a Medicare Advantage plan that has Part D benefits. While there are many good Part D plans available on the market, most come with a coverage gap or “donut hole.”

The Medicare Part D coverage gap happens when beneficiaries have spent a certain amount on prescription drugs that year, prompting a temporary limit on what the drug plan will cover for the rest of the calendar year. The limit may change from year to year; in 2023, Part D members will hit the donut hole once they have spent $4,660 on prescription drugs. Note: Medicare beneficiaries who use the Extra Help program to pay Part D costs do not have to worry about entering this coverage gap. Let’s talk about some ways to avoid hitting the prescription drug donut hole.

Five Tips for Avoiding the Medicare Part D Coverage Gap

Since the donut hole is triggered by spending a certain dollar amount on prescription drugs, the trick is to keep your drug costs as low as possible with the following five tips:

1. Ask for generic prescriptions

Many common prescription drugs have generic (non-name brand) alternatives that are a lot more affordable. Because the FDA requires that generic drugs have the same ingredients as the brand-name version and be proven to equally effective, you can feel comfortable switching from name-brand to generic to save yourself some money.

2. Ask for drug manufacturer’s discounts

If you take one or more brand-name or specialty drugs, you may be able to take advantage of discounts offered by drug manufacturers. Some pharmaceutical companies offer their drugs at a discount when you order them directly or through your doctor’s office – discount information may be available on the drug manufacturer’s website but you can also ask your doctor or healthcare provider if any discounts are available. Your pharmacy may also have a pharmaceutical assistance program that’s worth looking into.

3. Set-up auto delivery of your prescriptions by mail

If you have a prescription for a drug that can be prescribed in larger supplies, it’s worth looking into a bulk order program. Many Medicare Part D plans offer prescription medications at a discounted price if you order a three-month supply by mail instead of picking up a 30-day supply at the pharmacy. Another option is to ask your local pharmacy if they can provide a 90-day supply of your prescription at the same price as the mail-order plan.

4. Look into Extra Help or state assistance programs

Low-income and low-resource seniors may qualify for Extra Help to help pay for prescription drug costs. There may also be state assistance programs such as Hawaii RX that help pay for a small to large percentage of out-of-pocket costs for prescription drug coverage. The specific qualification threshold may change each year so it’s always a good idea to check with your Medicare agent or’s pharmaceutical assistance program search to see if you qualify.

5. Shop for the best prescription drug plan each year during AEP

Each year during the Annual Enrollment Period (October 15-December 7), Medicare beneficiaries have the opportunity to shop for and choose a new Part D or Medicare Advantage plan. Plan options change from year to year so it’s always a good idea to see if there is a better plan out there for you. A 2019 eHealth study found that the vast majority of seniors enrolled in a Medicare prescription drug plan could save money by switching to a different plan.

There are plans that offer additional coverage once beneficiaries run into the Medicare drug coverage gap, but they usually come with a higher monthly premium. Ask your Medicare agent for some options that may suit your needs.

Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. We are the only insurance agency in Hawaii contracted with EVERY Medicare Advantage plan, which means we are able to offer unbiased advice; all at no cost to our clients.

At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.


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