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Changes To The 2019 Part D Coverage Gap

Question: I just picked up my medication and the cost changed? It is a different amount than it has been, what happened? The clerk told me I hit the coverage gap. When and why does that happen?

Answer: This comes a little early in the year for that question, but you must take expensive medication. Usually we start hearing that question in August and September. Your medications costs change at the pharmacy because of how Medicare Part D phases of coverage work. I will explain that, I will also today be talking about some changes coming in the future (2019) to Medicare Part D coverage!

The Medicare Part D coverage has four phases of coverage: Deductible, Initial Coverage, Coverage Gap and Catastrophic Coverage. The cost of your medications leads you through those phases of coverage. The Deductible for most plans (if you have one) is $405 this year. That means you pay full price for the first $405 worth of medication. In the next phase- Initial Coverage- you pay approximately 25% of the cost of the medication, and the insurance company pays the remaining 75 percent of the cost of the medication. That is on average, so your actual costs may be a little different.

Once your total medication cost (full price of the medications) reaches $3750 you move to the Coverage Gap phase. The media often calls this the Donut Hole. This is where costs usually increase for you. Your cost of Brand Name medication becomes 35 percent of the total cost of the medication, and your cost of Generic medications become 44 percent of the total cost of the medication. This coverage lasts until you have spent $5000. Then you move to the Catastrophic Coverage phase where you only pay 5 percent of the total cost of the medications. The Catastrophic Coverage lasts for the remainder of the year. Most people never reach this phase of coverage.

For you to have reached the Coverage Gap in the first part of April, your medications must be very expensive, but that is certainly possible. Your co-pays up to this point, may not have been expensive, but your medication’s full cost is expensive. During the Coverage Gap/Donut Hole, your cost will be 35 or 44 percent (Brand Name or Generic). So, your $1000 full cost of medication could become $350 or $440. That is some expensive medication to pay each month. Once you have moved through the Coverage Gap, you will move to the Catastrophic Coverage where you will pay approximately $50.

Let’s use the following medications: Lisinopril (Generic), Actos (Brand Name) and Pioglitazone Hcl (Generic for Actos). I am also using pricing for a 30-day supply of each medication. I am NOT giving you the name of the insurance product I used because that does not matter. I am trying to illustrate how the costs can change.

During the Deductible you will pay full price; Lisinopril=$1.30, Actos= $606.08 and Pioglitazone=$1.21. Now the Deductible is only $405, so Actos uses all of that and moves you into Initial Coverage. So you won’t pay $606, but closer to $405 for Actos during the Deductible.

During the Initial Coverage you could pay Atenolol=$1.00, Actos=$95.00 and Pioglitazone=$1.00. Those prices last until the total price (real cost) of the medications add up to $3750. That would take approximately 6 months, maybe a little longer (six refills/months). Once your total cost of your medications has gotten to $3750 you move to the Coverage Gap.

During the Coverage Gap you would pay; Lisinopril=$.57, Actos=$212.13, and Pioglitazone =$.54. This will last for a number of months depending on how many generics and brand names you take.

If you move to the last phase of coverage, Catastrophic Coverage, your co-pays would change again. During the Catastrophic Coverage you would pay; Lisinopril=$1.30, Actos=$30.30 and Pioglitazone=$1.21.

As you look at those prices you see some pretty significant pricing changes on the Actos. You also may note that Lisinopril costs more during Catastrophic Coverage than it did during the Coverage Gap. That is because during Catastrophic Coverage the minimum a Generic can cost is $3.35 or $8.35 per Brand Name medications, so Catastrophic Coverage can be more expensive for some medications. That can happen with both Name Brands and Generic equivalents.

Sometimes I hear people say they won’t take their medication because it costs too much, and that is NOT necessarily a good decision. You should work with your physician and maybe your pharmacists to see if there are alternative, cheaper medications available.

I also promised to talk about some exciting changes happening in 2019. The Coverage Gap was legislated to be removed by 2020, but in the recently passed Federal Spending Budget they moved that forward to 2019! Beginning 2019, the Coverage Gap no longer exist. After the deductible of your plan has been met, you will pay approximately 25 percent of the cost of all your medications until you have reached the Catastrophic Coverage Threshold. In the situation we just illustrated, that may save you a significant amount of money. You will never have the stage where you pay $212.13 for your Actos. You will go from full price (up to the $405 deductible) to $95 to $30.30 over the course of the year. Most of the year you will pay $95 per month.

I am very excited about this change! This will save seniors everywhere quite a bit a money. It was scheduled to happen in 2020, but 2019 is a much better timeframe. That is right around the corner!

I also want to recommend you look into EPIC. EPIC is the New York State Prescription Drug coverage available to those seniors (over 65) who live in New York State, make less than $100,000 for a couple or $75,000 for a single person and who have a Part D prescription drug plan. The EPIC contact information is 1-800-332-3742, or the website: health.ny.gov/health–care/epic to find out more about EPIC and how it can help. EPIC would be secondary coverage for your prescription medications. EPIC stands for Elder Pharmaceutical Insurance Coverage. This would be in addition to your Part D plan, but could save you money now and in the future. So if you do not have EPIC already, please look into further to get more information.

I hope that this helps to explain why your medications cost so much. I also hope that you find a way to help pay for those increased costs or reduce the costs you pay.

To contact Janell Sluga, GCMC with insurance questions or concerns, please call 720-9797 or e-mail at janells@lutheran-jamestown.org.

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