Patient Message Board

Please read below to see what is going on across the country. The situations below illustrate the effects of Medicare Part D. They are the testimonials of real people with Medicare, caseworkers, and family members who have submitted their stories, written in their own words.

Charley Smith takes three medications to treat his high blood pressure and high cholesterol. These medications will cost him about $1,200 in 2010. Charley is switching to a Medicare prescription drug plan that has a low premium and offers the standard Medicare drug benefit, including a deductible and no drug coverage in the donut hole.

This is what his prescription medications will cost in the plan he has selected:

• Charley will pay a deductible of $310
• He will then pay 25% of the remaining $890 cost of his medications ($1200 - $310 = $890). His out-of-pocket cost during this initial coverage period will be $223 ($890 X 25% = $223)
• Since Charley did not reach the $2830 initial coverage limit, he will not enter the donut hole.

Charley’s total estimated annual out-of-pocket prescription drug cost with his Medicare Part D plan will be $310 + $223 = $533 (plus his monthly premiums for the Medicare Part D plan).

Mike Jones takes five medications to treat his type 2 diabetes, high blood pressure, and high cholesterol. These medications will cost him about $3,800 in 2010. Mike is planning to join a Medicare prescription drug plan that offers the standard Medicare drug benefit, including a deductible and no drug coverage in the donut hole.

This is what his prescription medications will cost in the plan he has selected:

• Mike will pay a deductible of $310
• He will then pay 25% of the cost of his medications for the next $2520, until he reaches the coverage gap. His out-of-pocket cost during this initial coverage period will be $630 ($2520 X 25% = $630)
• He will then enter the donut hole and be 100% responsible for the remaining cost of $970

Mike’s total estimated annual out-of-pocket prescription drug cost with his Medicare Part D plan will be $310 + $630 + $970 = $1,910 (plus his monthly premiums for the Medicare Part D plan).

Sarah takes two expensive brand name medications to treat her rheumatoid arthritis and asthma. These medications will cost her about $8400 in 2010. Sarah has selected a Medicare prescription drug plan that has no deductible and no drug coverage in the donut hole.

This is what her prescription medications will cost in the plan she selected:

• Since Sarah has no deductible, she will pay 25% of the cost of her medications during the initial coverage period of $2830. Her out-of-pocket cost will be $708 ($2830 X 25% = $708)
• She will then enter the donut hole and be responsible for 100% of the cost of her medication until she reaches an out-of-pocket limit of $4,550
• Since she has already spent $708 out-of-pocket, she will be responsible for an additional $3,842 while in the donut hole ($4,550 - $708 = 3,842)
• At this point, the total amount that Sarah and her health plan have paid for her drugs is $6,672 ($2,830 during the initial coverage period + 3,842 during the donut hole = $6,672)
• Since the total amount of her drug costs is $8400, there is still an additional $1,728 that needs to be paid ($8,400 - $6,672 = $1,728)
• Sarah will only have to pay about 5% of the remaining drug costs, or $86.40; her drug plan will pay the remaining amount ($1,728 X 5% = $86.40)

Sarah’s total estimated annual out-of-pocket prescription drug cost with her Medicare Part D plan will be $708 + $3,842 + $86.40 = $4,636.40 (plus her monthly premiums for the Medicare Part D plan).

An example to help estimate when you enter and leave the Donut Hole?

Suppose an example beneficiary, Mr. Smith, takes an expensive medication such as Betaseron (with an estimated retail cost of $775 for eight 0.3 MG vials per month), he will never pay more than $4550 out of pocket before the Catastrophic Coverage phase of his plan is reached. Assuming Betaseron is the only medication that Mr. Smith uses, he will enter into the Donut Hole in the third month of his plan ($2830 / $775).

Mr. Smith will then emerge from the Donut Hole into the low cost Catastrophic Coverage around the seventh month of his plan ($6440 / $775). In this way, Mr. Smith will receive low cost Catastrophic Coverage for the remainder of the year (or approximately five+ months).

During the Catastrophic Coverage phase, Mr Smith's monthly medication costs should be reduced to $38.75 or 5% of $775. Please note: if Mr. Smith enrolled in a Medicare Part D plan where his medications are also covered through the Donut Hole, Catastrophic Coverage may never be reached because Mr. Smith's true out of pocket medication costs would never exceed $4550 (with a plan providing Donut Hole coverage, Mr. Smith would probably pay around 25% of the retail price or 193.75 (assuming this medication is listed as a Tier IV or "specialty" drug) -- twelve months of coverage = $2325 out of pocket cost).