UNITED STATES—Toni: Last year, my husband got into the “donut hole” in September. I can see from the Part D statement he receives monthly that he is rapidly approaching the donut hole and it is only the beginning of May. He has only added one new prescription, Xarelto since last year and is entering the donut hole earlier than last year.

We can afford his co pays of $180 per month, that he paid at the pharmacy. The monthly Part D statement says the prescription drugs cost is $1250 per month. This confuses me?

Please give me options to help control this cost! Thanks Jennifer from Dallas, TX.

Jennifer: Your husband’s prescription drug problem is a typical problem since the cost of brand name prescriptions such as Xarelto have risen dramatically. You can afford his $180 co pays, BUT… have no idea that the true cost of his prescription drugs is now $1250 each month.

Once his Medicare Part D prescription drug plan and the co pays he pays totals $4130 for 2021 for his covered drugs, then your husband has entered the famous “Donut Hole” or coverage gap.

He must pay to $6550 to get out of the “Donut hole.” He will pay 25 percent cost for a brand name drug and the brand name drug manufacturer will pay 70 percent of that covered brand name drug cost with the remaining 5 percent cost paid by the prescription drug plan which he enrolled in.

What happens if your brand name drug is not a “covered” brand name drug on your specific Part D plan?  Your husband will have to pay 100 percent of that brand name drug.

Generics cost a considerable amount less and for 2021, the cost is a 25 percent co-pay of the generic cost instead of 25 percent co-pay for the cost of an expensive brand name prescription drug when in the “Donut hole.”

That is why it is important when choosing a Medicare Part D prescription drug plan whether beginning Medicare for the first time or during Fall’s Medicare’s annual enrollment period to be sure all prescriptions are covered on one’s Medicare Part D plan.

Do research prior to enrolling in a Part D because one cannot change if the wrong choice for a Part D plan is made until Medicare’s next annual enrollment period which is from October 15  to December 7 every year.

January 1 of each year, the process starts all over again, with a new Medicare Prescription Drug plan and different costs, deductibles, and a new Donut hole.

Toni’s Tips to help you stay out of the Donut Hole or not get in it as soon!

  • Visitmedicare.gov when selecting a Medicare Part D plan whether it is your first time or changing during Medicare’s Annual Enrollment Period in the fall.  This is an accurate way to view the cost of drugs and which plan and pharmacy is most cost effective.
  • Talk to your doctor or doctors about which brand name drugs can be changed to generics.
  • Get samples from your doctor.
  • See what generics are on GoodRX.com website or in a $4 or $5 generic prescription drug programs at HEB, Wal-Mart, and Costco etc.…  Pay for the generics out of your pocket.
  • Sign up for Toni’s newsletter and receive a “free” copy of the new Medicare Prescription Drug Survival Guide e-book version at www.tonisays.com.

2021 Confused about Medicare and LTC Zoom webinar is Thursday, June 24 at 4 p.m. Visit www.tonisays.com to sign up for Toni’s new webinar event.

Toni King, Medicare author/advocate is giving a $5 discount to the Toni Says® readers on the new 2021Medicare Survival Guide® Advanced book at www.tonisays.com. Have a Medicare question? Call 832-519-8664 or email info@tonisays.com.