Roosevelt T. of Sacramento was surprised when he called his pharmacy recently.  “The doughnut hole had caught up with me,” said Roosevelt, who takes six prescriptions. “I just didn't know about it.  I've got to pay $3,600 before they (his Part D drug plan) starts paying again.  I think it stinks.”

No other health insurance has ever been structured like Medicare Part D.  Many of you may have been shocked to pay the full price for your prescriptions even though you continue to pay monthly premiums for your drug coverage.  You fell into the “doughnut hole.”

Those of you who hit the doughnut hole generally have high-priced drugs, or require multiple prescriptions.  You may even have heard about the doughnut hole when you signed up for your plan, but it’s complicated to figure out.

Under the government’s “standard” Part D benefit, beneficiaries generally pay a $250 deductible, then a co-payment that’s 25% of the cost of your prescriptions, with the drug plan covering the rest.  When your combined spending between you and your plan reaches $2,250, you have hit the doughnut hole.  That gap in coverage will continue until you have paid a total of $3,600 out-of-pocket, not counting your premiums.  After that you receive “catastrophic coverage.” You pay only 5% of your drug costs or a small co-payment for the rest of the calendar year.

Juliette Cubanski, a policy analyst with the nonpartisan Kaiser Family Foundation, said no one knows for sure how many people will actually be affected by the gap in coverage. She put the figure at anywhere from 3 million to 8 million nationwide.

One option for beneficiaries is to change to another drug plan that offers more coverage in the doughnut hole.  These plans charge a higher monthly premium.  In addition, many of the plans offering coverage for the gap only cover generics, not brand-name drugs.  You must carefully estimate whether the extra premiums are worth the extra cost.  Your chance to switch starts during the Medicare Open Enrollment from November 15 to December 31.

Members of Congress are hearing about the doughnut hole complications from their constituents.  As a result, several pieces of legislation have been introduced as bills to ultimately fix the doughnut hole dilemma.  Now is your opportunity to get the attention of Congress and change the prescription drug program for the better.  Let’s tell Congress to “fill the hole.”

November 2006