Meds for Elders-- Closing the "Donut Hole"

  1. This just in from the website. Good news for your older patients...

    People with Medicare save more than $4.1 billion on prescription drugs

    18 million with Medicare also receive free preventive services in the first seven months of 2012
    Nearly 5.4 million seniors and people with disabilities have saved more than $4.1 billion on prescription drugs as a result of the Affordable Care Act, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today. Seniors in the Medicare prescription drug coverage gap known as the "donut hole" have saved an average of $768. During the first seven months of 2012, the new health care law has helped nearly 18 million people with original Medicare get at least one preventive service at no cost to them.

    "The health care law has saved people with Medicare over $4.1 billion on prescription drugs, and given millions of beneficiaries access to cancer screenings, mammograms and other preventive services for free," said Secretary Sebelius. "Medicare is stronger thanks to the health care law, saving people money and offering new benefits at no cost to seniors."

    The health care law includes benefits to make Medicare prescription drug coverage more affordable. In 2010, anyone with Medicare who hit the prescription drug donut hole received a $250 rebate. In 2011, people with Medicare who hit the donut hole began receiving a 50 percent discount on covered brand-name drugs and a discount on generic drugs. These discounts and Medicare coverage gradually increase until 2020 when the donut hole is fully closed.

    The health care law also makes it easier for people with Medicare to stay healthy. Prior to 2011, people with Medicare had to pay extra for many preventive health services. These costs made it difficult for people to get the health care they needed. For example, before the health care law passed, a person with Medicare could pay as much as $160 for a colorectal cancer screening. Now, many preventive services are offered free of charge to beneficiaries, with no deductible or co-pay, so that cost is no longer a barrier for seniors who want to stay healthy and treat problems early.

    In 2012 alone, 18 million people with traditional Medicare have received at least one preventive service at no cost to them. This includes 1.65 million who have taken advantage of the Annual Wellness Visit provided by the Affordable Care Act - over 500,000 more than had used this service by this point in the year in 2011. In 2011, an estimated 32.5 million people with traditional Medicare or Medicare Advantage received one or more preventive benefits free of charge.

    For state-by-state information on savings in the donut hole, please visit: (PDF - 206 KB)

    For state-by-state information on utilization of free preventive services, please visit: (PDF - 281 KB)

    Medicare Drug Discounts

    The Affordable Care Act includes benefits to make your Medicare prescription drug coverage (Part D) more affordable. It does this by gradually closing the gap in drug coverage known as the "Donut Hole."

    What This Means for You

    Starting January 1, 2011, if you reach the coverage gap in your Medicare Part D coverage, you will automatically get a 50% discount on covered brand-name drugs. You receive the discount when you buy them at a pharmacy or order them through the mail, until you reach the catastrophic coverage phase.
    Watch Video

    • You will also get a 7% discount on generic drugs while in the Donut Hole.
    • You can expect additional savings on your covered brand-name and generic drugs while in the coverage gap until the gap is closed in 2020. See the schedule below for information on what you'll pay for drugs while you are in the coverage gap:
      • 2012: you'll pay 50% for brand-name drugs and 86% for generic drugs
      • 2013: 47.5% for brand-names and 79% for generics
      • 2014: 47.5% for brand-names and 72% for generics
      • 2015: 45% for brand-names and 65% for generics
      • 2016: 45% for brand-names and 58% for generics
      • 2017: 40% for brand-names and 51% for generics
      • 2018: 35% for brand-names and 44% for generics
      • 2019: 30% for brand-names and 37% for generics
      • 2020: 25% for brand-names and 25% for generics

    Some Important Details
    • You can get the new savings starting in 2011 if all of the following are true:
      • You're currently enrolled in a Medicare Prescription Drug Plan (including employer group health and waiver plans) or a Medicare Advantage Plan that includes prescription drug coverage.
      • You don't get Extra Help. This is a Medicare program to help people with limited resources pay drug costs.
      • You have already reached the coverage gap.

    • You don't need to do anything to get the discount. If you have reached the coverage gap and you don't get a discount when you pay for your brand-name prescription, you should review your next Explanation of Benefits (EOB) notice. You can work with your drug plan to make sure that your drug records are correct.
    • Although you will pay only 50% of the price for the brand-name drug, the entire drug cost will count toward the amount you need to qualify for catastrophic coverage.

    For More Information

    Posted: December 27, 2010
    Last updated: July 6, 2012
    Last edit by Joe V on Aug 21, '12 : Reason: formatting
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  3. by   wooh
    Informative and good to hear!
  4. by   DoGoodThenGo
    All very well and good but all that palaver wouldn't be needed if Medicare simply did what all insurance schemes do; establish a formulary and use the vast purchasing power of the federal government to drive down the costs for meds.
  5. by   Not_A_Hat_Person
    Unfortunately, Part D doesn't allow Medicare to negotiate drug prices. The VA can do it, but Medicare can't.
  6. by   DoGoodThenGo
    Quote from Not_A_Hat_Person
    Unfortunately, Part D doesn't allow Medicare to negotiate drug prices. The VA can do it, but Medicare can't.
    Yes, one remembers how that all went down during the run up to Bush's creation of Medicare's drug coverage scheme. While the idea was floated and many could see the benefit of the federal government using it's purchasing power to get the best deal for pharma dollars, it struck fear in the big drug companies, so they fought back. In the end not only did the idea not make it into the final bill, the new Part D was forbidden by law from negotiating prices.

    So we were left with mess of a unfunded drug program for seniors that was bankrupting the country until ACA which is supposed to be the next best thing since sliced bread on this matter.

    Big Pharma with it's global reach has more than had enough of dealing with various world government's national drug price controls, and aren't about to sit down and let the largest market (USA) go the same way. True under ACA they made deals for give backs and or otherwise reductions in some prices but only because the scheme promises them a large new market (all those previously un or under insured) for their goods.

    The US should simply establish one formulary bringing in all agencies including the VA, Tricare and anyone else who purchases pharma.