Episode 58 - Navigating the Medicare Donut Hole: Understanding and Overcoming the Coverage Gap

Welcome, I'm Diane Carbo with Caregiver Relief. Today's topic is on navigating the dreaded Medicare donut hole, understanding and overcoming the coverage gap. Navigating the complexities of Medicare, especially the infamous donut hole in Part D, can be daunting task for many. Understanding what the donut toll is and its implications and exploring vital solutions like MyFreePharmacyPlan.

org are essential for Medicare beneficiaries to manage their prescription costs. effectively and enjoy savings as well. This audio cast is going to delve into the intricacies of the Medicare donut hole, and I'm going to present a strategic solution to circumvent this coverage gap. So what is the donut hole in Medicare Part D?

The Medicare Part D donut, formerly known as the coverage gap, refers to a period of time within the Medicare drug plan where there is a temporary limit on what the plan will cover for your medications or drugs.

After spending a certain amount on covered drugs, beneficiaries enter this donut hole, leading to higher out of pocket expenses per prescriptions until they reach the catastrophic coverage threshold. I experienced this about two years ago when I was prescribed duloxetine to help me manage my chronic pain.

I'll tell you what, I was so glad to find a medication that seemed to work for me and help me manage my pain. It didn't make me feel groggy, and yet it calmed my pain. My neuropathies. You can imagine how shocked I was to get a call from my mail order pharmacy that I hit my donut hole. Now having worked with seniors for decades, I was well aware of the dreaded donut hole.

Seniors for decades have been struggling as they hit their donut hole. Hitting the donut hole has caused pain and suffering to many seniors over the decades. This is the time the seniors become non compliant with their medication regime. They have been forced to choose between eating, paying bills, and taking their life saving medications.

This was one of those moments for me. When I asked the pharmacist what the cost of the medication was going to be for me, he replied, Oh, that'll be 700. To say that I was totally shocked was an understatement. They were telling me 700 for 30 days of duloxetine. So this was a life altering decision for me.

There's no way I was going to pay 700 for a month for the next two months. There's no way I could have afforded that. So I made a very difficult decision. This is one that so many seniors have made over the decades. I've seen it I've personally now experienced it. I had to stop taking the duloxetine.

My years of nursing had made me well aware that this decision was going to cause me withdrawal. And boy did it. Diloxetine is also an antidepressant that is used off label for chronic pain. Abruptly stopping an SSRI can lead to withdrawal symptoms often referred to as SSRI discontinuation syndrome.

Withdrawal symptoms from SSRIs are relatively common. These symptoms can emerge when individuals suddenly cease taking their antidepressant medication. Symptoms can range from flu like effects, sleep disturbances, and nausea, to feelings of imbalance, electrical shock sensations, and restlessness. So here I was, at 68 years old, being held hostage to a medication that I could not afford anymore.

And I will be honest, the withdrawal was brutal. At that time, I made the decision to never be held hostage to a medication or the insurance industry again. So let me explain the dreaded donut hole. The dreaded Medicare donut hole. In 2023, the Medicare Donut Hole comes into effect after a beneficiary and their plan spend a combined 4, 430 on covered drugs.

Upon reaching this threshold, the individual enters the Coverage gap, where they typically pay 25 percent of the cost for both brand name and generic drugs until their out of pocket expenses reach 7, 050, at which point catastrophic coverage begins, significantly lowering the cost to the consumer again.

Now, we are in 2024 and the Medicare donut hole or the coverage gap in Part D prescription drug plans begins with the total retail value that covered exceeds 5, 030 and lasts until out of pocket spending reaches 8, 000. During this phase, beneficiaries are responsible for paying 25 percent of costs for both generic and brand names.

Notably, in 2024, there will be no cost sharing for those who enter the catastrophic coverage phase. Oh, dear lord, this, all this. Gobbling goop makes me nuts. It's convoluted on purpose. For 2025, significant changes are set to take place under the Inflation Reduction Act. These changes include introducing a new 2, 000 out of pocket spending cap and the elimination of the coverage gap phase.

Additionally, there will be a higher share of drug costs paid by Part D plans in the catastrophic phase, along with a new manufacturer price discount and reduced liability for Medicare in this phase. Moreover, there will be changes to plan costs and the manufacturer price discount in the initial coverage phase.

The out of pocket drug spending for Part D enrollees will be capped at 2, 000, indexed to rise each year after 2025 at the rate of growth in per capita Part D cost. All this means instead of being responsible for 7, 000 or 8, 000 out of pocket, it's now going to be responsible for 2, 000 out of pocket.

This is negatively going to impact the diminishing or the middle class, because they won't qualify for certain programs that help those with no Money the poor, the indigent and the wealthy will be able to afford the 2000 dollar a rate. in 2025. So let's talk about the coverage gap and the implications.

 The coverage gap or the donut hole signifies a period of reduced insurance coverage. For many, this results in higher out of pocket expenses for medications posing challenges. For the potentially impacting medication adherence, it's really tough.

People have heart attacks and strokes and withdrawal symptoms. They don't take their blood sugars or insulin the way they should. They don't take their hot blood pressure medications the way they should. And over the decades,

I have seen this have negative impact on so many seniors. How does the donut hole work in Medicare? Once in the donut hole, beneficiaries pay a percentage of the drug cost rather than a flat copayment. This change in cost sharing continues until they spend enough to qualify for catastrophic coverage.

During this phase, Medicare covers a significant portion of drug costs, easing the financial burden. For me, I have so many seniors that have very limited incomes. Or for those who are on disability, their incomes are so limited that even a 2, 000 is a lot. I'm going to offer you a solution to the donut hole challenge, and that's myfreepharmacyplan.

org. As an RN for over 50 years, I have supported and cared for the elderly. I have seen the struggles with paying for the high cost of prescriptions and the devastating consequences of stopping or decreasing life saving medications. So when I learned of this revolutionary new pharmacy program, I wanted to shout the information from the rooftops.

This is a revolutionary approach to purchasing our prescription medications. An effective way to avoid the financial impact of the Medicare donut hole is through this new flat fee pharmacy. This innovative plan offers a flat fee model for medication procurement, circumventing the traditional insurance based formulary system.

So let me talk about the benefits of MyFreePharmacyPlan. org. You have predictable costs. With a flat fee for medications, beneficiaries Better budget their health care expenses without worrying about the fluctuating cost associated with the donut hole and in my free pharmacy, 800.

We have 800 of the most prescribed medications in, at no cost to you. So pay attention. Having the access to myfreepharmacyplan. org you'll also have comprehensive medication access. The plan provides access to a wide range of medications including those typically affected by the donut hole. Ensuring continuous and affordable access to necessary drugs.

I'll tell you what, One of the big things is people with their high blood pressure and diabetics. The diabetic plan is the lowest cost in the country for insulins and oral hypoglycemics and even your products to your supplies that you use.

We also eliminate the coverage gap worries by offering medications at a consistent rate. My free pharmacy plan effectively eliminates the concerns associated with the Medicare coverage graph. graph. It also enhances medication adherence. With reduced cost barriers, individuals are more likely to adhere to their medication regimes, leading to better health outcomes.

And there's, the simplicity and convenience of it is bar none. The plan simplifies the process by obtaining medications, providing a straightforward and hassle free alternative to traditional Medicare Part D plans. So how do you utilize MyFreePharmacyPlan. org? Enrolling in MyFreePharmacyPlan. org is a straightforward process.

Beneficiaries can sign. Up online, select their medications, and enjoy the benefits of a flat fee structure. That flat fee structure is based on the Netflix model. And it's 19. 95 for a person, a single person, who is purchasing their medications. And then there's the family plan, which is 29. 95. And with the family plan, I have one family.

That signed up with nine kids and we're saving them hundreds of dollars with my free pharmacy plan. You pay this one basic monthly fee And the medications we have available are free to you. In fact, my duloxetine is free We also have the lowest prices of diabetes products And we have negotiated with walmart to get your insulins at the lowest possible price Ever, and because we can't ship it.

You can go to your local Walmart store to get it. In conclusion, I'd like to say that the Medicare donut hole poses a significant challenge for many beneficiaries. But with solutions like MyFreePharmacyPlan. org, it's possible to mitigate its impact by offering predictable costs. Comprehensive medication access and eliminating worries about the coverage gap.

This plan puts more money back into the pockets of Medicare beneficiaries. In an era where health care costs continue to rise, My Free Pharmacy Plan stands out as a beacon of affordability and accessibility, ensuring that seniors can maintain their health without financial strain. And I want you to know, this is It's not an insurance plan, so you still, because we are required by Medicare to purchase a Medicare Part D plan I buy the lot, for me personally, I'm not telling you to do this, but I buy the cheapest one I can find since I can get my prescriptions through this plan.

And it's absolutely going to change the way we buy our medications because I just read where the pharmacies are increasing the prices on 500 medications and it's only going to get worse as we get older. So I want to update for Medicare Advantage medications.

Medicare Advantage plans may have different cost sharing structures, which can include varying deductibles.

This can sometimes result in lower out of pocket costs for medications compared to original Medicare, but it can also lead to higher costs depending on the plan structure and the specific medications and enrolling needs. There's also network restrictions with Medicare Advantage plans because they often have network restrictions, meaning that enrollees may need to use specific pharmacies to get the best pricing for their medications.

Going outside the network can result in higher costs. You also are going to be faced with annual out of pocket maximums. Unlike original Medicare Advantage plans have an out of pocket maximum, which can limit the total amount an enrollee pays for covered services, including medications in a year.

Once this limit is reached, the plan covers all costs for the rest of the year, which can be financially beneficial for enrollees with high medication costs. So I want to talk about the Medicare Advantage plans in 2024. The maximum out of pocket expense limits are set to change reaching up to 8, 850.

This change means that 4. 4 million members could see an increase in their maximum out of pocket expenses from 50 to as much as 5, 400. The maximum out of pocket limit caps the amount the beneficiaries will spend on health care co payments and co insurance for eligible Medicare A.

Inpatient or hospitalization and Medicare Part B, outpatient or doctor visit services, a higher maximum out of pocket expenses for beneficiaries for covered services before reaching the annual maximum cost threshold. However, Part A and Part B expenses will not exceed 8, 850 for an in network Medicare Advantage cost sharing plan, but this does not include Part D prescription drug expenses.

For plans Beginning in 2025, the maximum out of pocket limit for Medicare Advantage plans is set to be 9, 200 for self only coverage and 18, 400 for family coverage. This represents a 2. 6 percent decrease from the 2024 limits of 9, 450 for self only and 18, 900 for family coverage. Once beneficiaries reach this out of pocket maximum for the year, they will not be responsible for additional cost sharing for the essential health benefits for the remainder of the year.

All that's very convoluted and confusing. Anytime we're dealing with a government program, that's not unusual. The bottom line is we, as we are seeing a growing population, we are seeing our government doesn't have the funds to provide the care that we are going to need. So they're making us more financially responsible.

for paying for the services or choosing not to take those. The I can tell you right now it's meant to deter the use of the benefits. So I am, I'm real excited to share the myfreepharmacyplan. org with you. It can be a lifesaver as far as medications, especially when you're on medications that you don't have to pay so much for, but because of greed our pharmacy benefits managers decide what the prices are.

That's why we don't have an a transparent way to. purchase our medications. The pharmacy benefits managers of every pharmacy provide decide what their, what the consumer will pay. And it's a tough one. And this takes the pharmacy benefits manager out of the equation. I hope this helps you with your medication needs as we go forward.

I'm Diane Carbo with caregiverrelief. com.

​