For many senior citizens who have Medicare Part D, a fixed income makes it very difficult to pay for prescription drugs. The Medicare Part D coverage gap for those senior citizens who have a chronic condition, can be very difficult. At this time of year there is much talk about the coverage gap or donut hole. Why is it there, what is it, and how does it work?

To decrease the cost of Medicare’s Part D coverage, the coverage gap was created. The yearly limit for Part D is set each year. $2400 was the 2007 annual limit. $2510 is what the yearly limit was increased to in 2008. In 2009 the amount is $2,700. The amount is calculated on the total costs of the prescription medications that you receive. What the insurance company pays and your co-pays are included in this calculation. If the insurance company pays $500 and the recipient pays $50 for a prescription drug, the amount that goes towards is applied to the annual amount is the full $550.
When you are in the donut hole or coverage gap, you are responsible for the cost all of your prescription medication. There is coverage for your generic drugs when you are in the coverage gap. The cost of most generics is so small that the benefit of having them covered by a plan isn’t that much of a benefit. Everyone’s situation varies so for some patients it might be worth it to have coverage for their generics.

For Medicare people with chronic health conditions which often require high priced drugs for treatment, the donut hole can be reached in a matter of weeks. We have seen patients reach the coverage gap as soon as February. Steering people to use less expensive prescriptions when possible is the whole point for the coverage gap. This punishes those patients who must take expensive prescriptions because nothing else works. Enbrel is a drug for patients who have rheumatoid arthritis and the cost of it can cause the patient to reach the donut hole within 2 or 3 months. The option at this point is to pay for the prescription drug at full cost for several months until the catastrophic coverage portion kicks in or suffer the potentially disabling consequences of stopping their medication. About $1500 per month is the price of Enbrel. Few senior citizens can actually afford that.

Some people will be able to take advantage of patient assistance programs due to their lower income. One of the best ways to get low cost or free drugs is to talk to the drug manufacturer. Contact the company and ask about their Prescription Assistance Program. Most all drug manufacturers offer such programs, which enable patients to receive medicine they need at a price they can afford. You and your doctor will need to complete an application. Patient Assistance Programs run by drug manufacturers have been in existence for over 22 years. These programs are designed to assist eligible patients who can’t afford their prescription drugs due to low income or other financial hardships.

Drug manufacturers did not want their low income customers to be forced to make a choice between paying for life saving prescription medicine or for paying for rent or groceries. As a result, patient assistance programs came into being as part of the company's philanthropic efforts. Until relatively recently, very few patients knew about these programs or could follow the complicated application process that was necessary for participation. In many cases multiple applications had to be filed with several different drug manufacturers in order to gain access to prescription assistance programs.
The manufacturers seem to believe that offering information on their websites and toll-free numbers is all that patients need to access PAPs. They don’t grasp the inability of many people, particularly those on multiple prescription drugs from 2 or more physicians to follow through with the fragmented application process. It also places an unfair burden on the healthcare providers that are already overburdened with paperwork. Fortunately there are companies that will perform the task for people for a fee. These prescription assistance companies will generally coordinate the process from beginning to end. Of course the prescriptions are free and if patients are capable of doing it themselves they should, but for those people that just do not have the skills to do it themselves, the hiring of a firm to do the job is a better option than not taking the prescription medicine they need.