Examining the 'donut hole'

There have been many questions about the $250 rebates that some Medicare recipients will receive. Not everyone will get these. If you have a Medicare prescription drug plan (Part D), and are not getting Medicare Extra Help, and you reach the coverage gap (also referred to as the "donut hole"), then you will automatically receive a tax free, one-time $250 rebate. There are no forms to fill out. A check will be mailed to you.

Most Medicare drug plans have a coverage gap. This means after you and your plan have spent a certain amount of money, you have to pay all costs out-of-pocket for your drugs (up to a limit).

In some Medicare prescription drug plans, you may have to pay up to the first $310 of your drug costs. This is known as the deductible.

During the initial coverage phase, your drug plan pays 75 percent of the covered prescription drug costs after your deductible is met, and you pay 25 percent until the total drug costs (including your deductible) reach $2,830.

Once you reach $2,830 in total drug costs, you will be in the donut hole and you must pay the full cost of prescription drugs until your total out-of-pocket cost reaches $4,550. This annual out-of-pocket spending amount includes your yearly deductible and copay amounts.

When you spend more than $4,550 out-of-pocket, the coverage gap ends and your drug plan pays most of the costs of your covered drugs for the remainder of the year. You will be responsible for a copay of $2.40 for each generic drug and $6 for other drugs (or 5 percent, whichever is higher). This is known as catastrophic coverage.

The expenses outlined above only include the cost of prescription medications. It does not include the monthly premium you pay to the prescription drug plan.

Many people who have Medicare prescription drug plans never reach the gap, because they haven't spent the $2,830. These people will not get the $250 rebate, but they also will have spent much less on their prescription drugs.

The Senior Connection is a column provided by the Clinton County Office for the Aging. For more information about services for senior citizens, contact their office at 135 Margaret St., Suite 105, Plattsburgh or call them at 565-4620. Information is also periodically provided by the Behavioral Health Services North Caregiver Resource Center. They may be reached at 565-4543 or 565-4625.

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