Susan M., at age 69, has chronic asthma and a heart condition. That means her medications are costly. This year, under her Part D, Medicare plan, Susan’s medication costs reached $3,750.00 in the latter part of March. That cost level triggered the “coverage gap” commonly referred to as the “doughnut hole.” That meant thereafter Susan has had to pay 35% of the cost of her brand-name drugs and 44% of the cost of her generic drugs and will continue to do so until her out-of-pocket spending on drugs reaches $5,000.00 for the year. When she has paid out $5,000.00 on medications, Susan will pay only 5 percent of her drug costs for the rest of the year.

Many articles state that the doughnut hole is going away in 2019, but that is not an accurate statement. The doughnut hole has been narrowing since the passage of the Affordable Care Act (ACA) in 2010 and was scheduled to go away in 2020. When Congress passed the Bipartisan Budget Act of 2018, although the doughnut hole was not eliminated entirely, some of its negative effects are lessened for the coming year. Under the new law, in 2019 the cost of the Medicare participants’ share of the drug cost will be reduced to 25% of brand name drugs and to 37% of generic drugs.

Also, for 2019, the initial coverage limit before the gap kicks in has been raised to $3,820.00. However, to become eligible for catastrophic coverage reducing her payment to 5 percent, Medicare recipients will have to pay out $5,100.00 from their own pockets.  

For Susan, and all other Medicare recipients, which drug plan works best carries the impact of the sixty-four thousand dollar question. Choosing the best plan is dictated by the individuals’ prescriptions. Comparing plans is confusing because they all have different formularies, which are the list - created by a committee of physicians, nurse practitioners and pharmacists - of prescription drugs, both generic and brand name, which health care practitioners identify as having the greatest overall effect.

In addition to having different formularies, drug plans have differing covered drug lists, and tiers or drug classes. One plan might cover a specific prescription as a tier 2 generic and another cover the same prescription as a tier 3 preferred brand. Obviously, the cost of the drug will vary accordingly.

Medicare recipients are allowed only certain windows of time each year in which to change Part D plans. The period from October 15 to December 7 is referred to as the Annual Enrollment Period. The period from January 1 through March 31 is referred to as the General Enrollment Period.

The outlines for the new plans are usually released around October 1. Therefore, Susan and other Medicare recipients should begin this week looking for that information and for the “star ratings” given each of these plans. Star ratings are determined by: (1) customer service; (2) member experience with the prescription plan services; (3) accuracy in drug pricing and drug safety; and (5) changes in the plan’s performance and member complaints.

Medicare recipients may want to review the article titled Top 5 Medicare Prescription Drug Plans for 2019 found at https://www.medicarefaqs/top-5-medicare-prescription-drug-plans-for-2019.  They should read this article with the caveat that, since the 2019 plans have not yet been released, the list is merely a prediction from past plans. The article lists plans in this order: (1) SilverScript Choice, (2) Humana Walmart Plan; (3) Aetna Medicare Select Plan; (4) Express Scripts Medicare Saver and (5) AARP Medicare Rx Walgreens 1. 

Sandra W. Reed is an attorney with Katten & Benson, an Elder Law firm in Fort Worth. She lives in beautiful Somervell County, near Chalk Mountain.