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Things you should know about Medicare Part D - Part I of a series on Medicare Part D Prescription Drug Program - 'The Gap' is no

The Medicare prescription drug program is a part of the Improvement and Modernization Act of 2003. The original Medicare Part D drug program was to be managed by the federal government and was even more complicated than the plans that now exist.

The current plans are managed by insurance companies who have contracts with drug companies and pharmacies. There are hundreds of insurance companies nationwide offering coverage for Medicare Part D.

California alone has 121 insurance companies in 2007. Each company that is not an HMO offers three types of plans with different deductibles, premiums, and co-payments. Some offer gap insurance, require step therapy and have quantity limits.

One must very seriously and carefully consider insurance options before making a selection, because a person cannot change insurance companies until the next year. An insurance company can change the medications that are covered under their plans at any time during the year.

For this article, let’s consider one aspect of Medicare Part D coverage: the $2,500 limit. Since the federal government does not control the drug companies, insurance companies or pharmacies, there are no rules about how much any of these organizations can charge. These facts can mean that you may be paying a higher premium, higher deductible or more money for your drugs at one insurance company or pharmacy over another.

Since the total cost of your medications, including your deductible, is added up to equal your $2,500 limit, you may be reaching that limit faster at one pharmacy or with one insurance company than another.

“The Gap,” also known as the “donut hole,” is the period of time that falls after a Medicare Part D recipient has reached his/her $2,500 coverage limit but before he/she has spent a total of $3,600 on prescription medication for the year.

Gap insurance is additional coverage offered by some companies during this time. This insurance can be found in the plans with the most costly premiums but will cover generic drugs during the time between $2,500 and $3,600.

Brand name drugs must be paid in full by the Medicare Part D recipient during the gap with all current policies. However, additional coverage can be found for persons in various low income groups. The Web site Medicare.com has information.

More information about Medicare Part D will be presented in future articles. The next article will discuss electing insurance with step therapy and quantity limits and how to use the drug formulary.

Madelyn Lewis is a Registered Nurse in the community working with the Fallbrook Healthcare District to educate the public about Medicare Part D.

 

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