What on Earth is the Donut Hole? A Brief Explanation of Medicare Part D and the “Donut Hole”

NeedyMeds March 13, 2013

Today, we are hoping to provide answers to some of your questions about the Donut Hole! Tell us about your experiences. We would love to hear from you.

1. What is the donut hole? To answer that question, we first need to understand Medicare and Part D.

According to Jonathan Blum, Deputy Administrator and Director for the Center of Medicare at the Centers for Medicare and Medicaid Services, Medicare is the federal health insurance program for people 65 or older, people under 65 with certain disabilities, and people with End-Stage Renal Disease (permanent kidney failure). People with Medicare have the option of paying a monthly premium for outpatient prescription drug coverage. This prescription drug coverage is called Medicare Part D.

Basic Medicare Part D coverage works like this:

You pay out-of-pocket for monthly Part D premiums all year.
You pay 100% of your drug costs until you reach the $310.00 deductible amount.
After reaching the deductible, you pay 25% of the cost of your drugs, while the Part D plan pays the rest, until the total you and your plan spend on your drugs reaches $2970.00.
Once you reach this limit, you have hit the coverage gap referred to as the “donut hole,” and you are now responsible for the full cost of your drugs until the total you have spent for your drugs reaches the yearly out-of-pocket spending limit of $4,550.
After this yearly spending limit, you are only responsible for a small amount of the cost, usually 5% of the cost of your drugs.

2. What is the structure, e.g., cut-offs, coverage amounts and patient payment percentages?

The “donut hole” refers to a gap in prescription drug coverage under Medicare Part D. In, 2013, once you reach $2,970 in prescription drug costs (which include both your share of covered drugs and the amount paid by your insurance), you will be in the

Why do kids have unfilled prescriptions?

NeedyMeds March 6, 2013

You take your sick child to the doctor. An exam is done, a diagnosis made, a prescription written, and instructions given to the parent. The next step: a trip to the pharmacy to have the prescription filled so the child can start the medicine as soon as possible. Right? Why, then, did a recent study reveal that up to 25% of children’s prescriptions remain unfilled?

Investigators are currently examining whether electronic prescriptions are filled more often (because the patient does not have the opportunity to lose or misplace it), or if, in fact a written prescription serves as a tangible reminder to go to the pharmacy to get the prescription filled.

Other researchers are looking at the rate of prescriptions being filled as a result of a well-child visit versus that of a sick-child visit. Some early findings are showing that prescriptions given at sick-child visits are filled more often than those given at well-child visits.

For the uninsured and underinsured, the costs of prescription medications can be daunting. Even for those who have health insurance, co-pays and deductibles mean that many still struggle to afford the costs of

Vaccinations

To Vaccinate, Or Not?

NeedyMeds February 27, 2013

The development of vaccines to protect against potentially killer diseases likes polio, measles and pertussis (whooping cough) has been widely hailed as one of the crowning achievements of medicine in the 20^th century. As the table below shows, the incidence of these, and other diseases, decreased by between 95-100% once vaccines were given. Many of us can likely remember hearing stories of family members who died from these diseases, or who were otherwise seriously and permanently affected from having suffered from these diseases. But are we taking this standard of care for granted?

According to a recent study reported by Reuters, “Nearly half of babies and toddlers in the United States aren’t getting recommended vaccines on time – and if enough skip vaccines, whole schools or communities could be vulnerable to diseases such as whooping cough and measles.”

We are seeing the effects of “under-vaccination” already as outbreaks of pertussis (whooping cough) are becoming increasingly

Medication Adherence, Prescription Drugs

Your Good Health: Medication Adherence

NeedyMeds February 20, 2013

Last month, many of us made New Year’s resolutions and we were being deluged with advice about how to eat sensibly, how to exercise our way to fitness, and how to develop and keep healthy habits. But let’s get down to basics: how well do you follow your doctor’s advice?

Doctors will be increasingly held accountable for your overall health and wellness, and your progress towards sustained good health, under the Affordable Care Act (ACA). The ACA aims to increase the quality of care given and reduce the costs, thereby ensuring that the right care is given in the right place at the right time. More care has not proven to be better care, and reducing unnecessary and expensive screens and tests will go a long way to reducing health care costs.

But patients have a responsibility too – and that is to listen to your physician and follow their recommendations regarding nutrition, exercise and taking your medications as prescribed. “Medication adherence” or “medication compliance” are terms used to describe what patients do once they receive a prescription from their provider, including filling, and then re-filling when indicated,

Prescription Drugs

What Does “Off-Label” Mean?

NeedyMeds February 13, 2013

We often hear about drugs being prescribed “off-label.” Many patients have questions about what this means. Is it safe? Is it legal? How can we know that off-label use will help us get better?

Off-label use is the practice of prescribing pharmaceuticals for an unapproved indication, age group, dose or form of administration. We will explain more about this shortly.

But first, let’s look at how drugs are approved for use in our country.

In the U.S., the Food and Drug Administration Center for Drug Evaluation and Research review’s a company’s New Drug Application for data from clinical trials to see if the results support the drug for a specific use or indication.

If the drug is found to be safe and effective, it can be marketed for the specific condition for which it was approved by the FDA. Until recently, however, it was against FDA regulations for pharmaceutical companies or their representatives to market a drug for any conditions for which the FDA hadn’t approved.