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Maximizing Medicare prescription drug coverage

By Marlene Richter

By Marlene Richter
Community Outreach Manager,
Care Improvement Plus

Medicare beneficiaries take an average of 29 prescriptions per year, spending approximately $1,300 on medications annually. Individuals with chronic conditions such as heart failure often pay more than double that amount.

Fortunately, there is a voluntary program called Medicare Part D that helps beneficiaries pay for their prescription drugs. Beneficiaries can access prescription drug coverage either from a stand-alone Part D prescription drug plan or from a Medicare Advantage plan that bundles coverage of medical, hospital and prescription drug benefits in one plan.

Enrolling in Part D prescription drug coverage is one way beneficiaries can help manage their prescription drug costs, but they should be aware that all Part D plans include a coverage gap, which is often called the "donut hole." In the coverage gap, beneficiaries' out-of-pocket costs on their prescription drugs increase significantly.

The following tips may help them save money on their prescription drugs and make the most of their benefits.

1. Get help with
managing multiple

Beneficiaries who have a chronic condition that requires them to take multiple medications every day should consider enrolling in a Medicare Advantage Chronic Special Needs Plan.

These plans combine Medicare coverage with additional support services, some of which are designed to help ensure that members are able to afford their medications.

2. Understand how "donut hole" works

After spending $2,930 in out-of-pocket costs on their drug coverage, beneficiaries will reach the coverage gap. Currently, beneficiaries in the gap pay 50 percent of the cost of their brand-name prescriptions and 86 percent of the cost of generic drugs.

Beneficiaries should monitor their plan's Evidence of Coverage statement to get a clear sense of their drug expenditures and see how close they are to reaching the gap.

3. Apply for "extra help" with drug costs

For beneficiaries with limited income and resources, Extra Help is a federal program that provides an average of $4,000 of additional assistance with prescription costs.

Medicare beneficiaries must apply for this program, and the amount of assistance is based on annual income and assets. For more information about the Extra Help program, contact the Social Security Administration at 1-800-772-1213.

4. Take advantage of cost-savings on
prescription drugs.

Beneficiaries enrolled in a Medicare Advantage plan that includes drug coverage should check their plan details to see if they could save money on their prescriptions, such as by using mail-order pharmacy benefits, switching to generic or lower-tier drugs, or taking advantage of special programs available with some plans.

5. Explore "PAP"

Several pharmaceutical manufacturers sponsor Patient Assistance Programs (PAPs) that may reduce prescription drug expenses. For more information, contact the Partnership for Prescription Assistance program at 1-888-477-2669.

Additionally, Texas currently offers a State Pharmaceutical Assistance Program (SPAP) to help qualifying residents pay for select prescription drugs. To find out more about the Texas SPAP - Texas Kidney Health Care (KHC) - call 1-800-222-3986.

For more information about Medicare Part D, contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day, seven days a week. The State Health Insurance Assistance Program (SHIP) provides free counseling and support to help beneficiaries understand their Medicare coverage options, including prescription drug coverage. To contact the SHIP office in Texas, call 1-800-252-9240.