Help in the Part D Gap

If you are a member of Medicare or work with the Medicare population, you’ve heard the term “donut hole.” Here’s a short explanation of what the donut hole is and what is available to assist people through this gap in coverage.

The donut hole is a coverage gap in every Medicare drug plan, be it a stand- alone plan or a Medicare Advantage Plan. When the total cost of your medications reaches $2850, you enter the donut hole phase of your prescription coverage. How is the donut hole calculated? The full retail price of the medication is calculated each time you refill a medication. When this total reaches $2850 you have entered the donut hole. During this period you are responsible for paying approximately 47.5% of the retail cost of name brand medications and 72% of generics.

What can I do to lower my costs in the Donut Hole?

There are few things we look at when helping someone through the donut hole. Here is a short list – please contact us for a more detailed review.

A. Low Income Subsidy (LIS) or “Extra Help”: The Low Income Subsidy is a benefit offered through Social Security to help you with the cost of your drug plan and medications. If your income is less than $17,235 for an individual or $23,265 for a married couple AND if you have resources limited to $13,440 for an individual or $26,860 for a married couple*, you may be eligible for this assistance. “Extra Help” may pay for your monthly premium, annual deductible, and lower your medication co-payments.

(NOTE: *Social Security DOES NOT count your home, car or any life insurance policies as resources. Resources do include things such as bank account, stocks, and bonds.)

B. Prescription Advantage: Prescription Advantage is the State Pharmacy Assistance Program(SPAP) available to Massachusetts residents enrolled in Medicare. This benefit helps with medication co-payments during donut hole. Members are placed in one of six different assistance levels based on income only and household size. If you are:

  • Married with a combined income of less than $46,530 annually, OR single with an income less than $34,470, you are eligible for Prescription Advantage and will pay no fee for this benefit.
  • If your income is over these limits OR if you are under the age of 65, contact us for a more detailed review. You may still benefit from this state program.

(Note: *Prescription Advantage DOES NOT count your resources or assets.)

For more information on any of these benefits and programs and to request applications, contact the MCPHS Pharmacy Outreach Program at 866.633.1617.