On May 29, 2010 my husband and I were enjoying a vacation in the Pacific Northwest when we received a “frantic” call from my sister-in-law who was staying with my 92-year-old mother-in-law. We had ordered a refill of Mom’s medication through her Medicare Part D plan. The plan called to see if it was okay to put a $1,200 charge on my credit card. “But I thought Mom has Medicare Part D prescription drug coverage” my sister-in-law exclaimed.

Mom does have a Part D plan but she had reached the “donut hole” or coverage gap in the plan. How did this happen?

Under the basic plan (like the one Mom has), this year there is a $310 deductible, after that there is a $310–$2,830 co-share. The plan pays 75% and Mom pays 25% of the cost of the medication. Then, once she and the plan TOGETHER have paid $2,830, the Medicare plan stops paying for the next $3,610.

In November Mom will reach “catastrophic coverage” where she will have spent a total of $4,550 out of pocket for her medications ($310 deductible, $630 co-share (her 25%) and the $3,610 during the donut hole or coverage gap). At this point the Medicare plan will pay 95% of the costs for the rest of the year.

Anyone who reaches the “donut hole” will receive a $250 rebate check from Medicare approximately 2 months after hitting the donut hole. This check will automatically come to the address that Medicare and Social Security have on file. The Medicare beneficiary does not have to do anything to receive the payment. It is important that the Medicare community be aware of the potential for fraudulent scams to get personal information. They should be aware that neither Medicare nor Social Security will ask for personal information (like your bank account number) by phone and that the rebate is automatic.

Is there relief in sight? Yes, eventually, by 2020 the donut hole will completely disappear and Medicare Part D plans will have continuous coverage. In 2011, when Mom once again will probably hit the donut hole, she will have a 50% savings on her name brand drugs.

If you need more information on Medicare or Medicare Part D, you can call 1-800-Medicare (1-800-633-4227) or access their website at www.medicare.gov or you can call the Hawaii State Health Insurance Assistance Program (SHIP) — locally known as the Sage PLUS Program. It is a certified volunteer based program that provides unbiased counseling to individuals, their caregivers and family members on Medicare topics. Sage PLUS can be reached at 586-7299 and 1-888-875-9229, or online at www.hawaiiship.org. ■

About the writer: Pamela Cunningham is coordinator for Hawaii SHIP (Sage Plus Program), and may be reached at the links above.