Talk to your doctor about switching to generics, review your Part D plan annually

Cheri Brown

Dear Medicare Cheri,

I have Medicare with a Supplement and a Part D prescription drug plan. My drug costs just increased significantly. The pharmacist said I was in a Coverage Gap. This is frustrating. I’m on a fixed income.

Painful Part D

Dear Painful,

All Medicare Prescription Drug plans are designed the same way, whether they are stand-alone plans or part of a Medicare Advantage plan. The dollar limits change annually. Every company chooses a list of medications they’ll cover called a formulary. Medicare reviews the formulary and ensures it meets its standards. The insurance company creates drug tiers and each tier has a co-payment the insured pays when they fill a prescription. There are four phases to Medicare Part D plans.

First is the deductible phase; the insurance company chooses an amount, which can be $0 or up to $505. The next phase is the initial coverage limit. During this time all medication on the formulary has a co-payment or co-insurance. Medicare tracks the cost of the co-payments as well as the amount the insurance company pays. When this amount totals $4,660, the insured falls into the Coverage Gap also known as the donut hole.

During this Gap phase, the insured (you) pay 25 percent of the cost of the medication. This is the phase you are in, and it can be painful. Medicare continues to track payments made by you, themselves, the drug maker, the pharmacist and the insurer. It is a complicated formula, and when 95 percent of all the prescription drug costs total $7,400 (the fee to fill the prescription and the 5 percent the insurance company pays are not counted) the insured then falls into Catastrophic Coverage phase for the remainder of the year. In this phase the insured pays a small co-insurance or co-payment for each prescription. By reviewing your statements for your drug benefits you can see where you are in the process. Fortunately, most people on Medicare have all medications covered during the initial period and do not participate in the Coverage Gap or Catastrophic Coverage phases.

What can you do? Talk to your doctor about switching to generics, review your Part D plan annually, contact your prescription manufacturer about assistance programs, and apply for low income subsidy, a program to help pay drug costs.

Dear Medicare Cheri,

I have been married for more than 40 years and have not worked outside the home since then. I turn 65 next year and am worried about qualifying for Medicare. I have been told I won’t have health insurance since I didn’t work long enough. If my spouse and I were to divorce will I still qualify?


Dear Worried,

You qualify for Medicare based on your spouse’s history, so you need not worry about qualifying. Medicare is based on working (or being married to someone who worked) 40 quarters of a lifetime. You should qualify once you turn 65 based on your spouse’s history and this will continue even if you should get divorced.

Best wishes,

Medicare Cheri