Doughnut Hole

WaPo reported Millions of older Americans are confronting a temporary break in their Medicare drug coverage this month that will require them to pay the full cost of their prescriptions or face the painful prospect of going without.

Before part D was enacted, they would have been paying for all of them all along.

This is the "doughnut hole" in the new Medicare drug benefit that began in January, and advocates for seniors say there is nothing sweet about it. Some seniors knew nothing of the coverage gap until they were hit with a bigger drug bill, advocates say.

Then they were not paying attention. I knew about it from the start. I decided not to sign up for Part D because the premiums would be more than my drug costs, but I knew if I had, the doughnut hole was there.

"Virtually everyone who calls to say they've been denied coverage, they're shocked," said Robert M. Hayes, president of the Medicare Rights Center, a nonprofit that helps seniors navigate Medicare. "Trying to explain that this is the way the program was created by Congress angers folks who think it makes no sense. Many people feel blindsided."

Would they have preferred paying for all of their drugs all year, or would they have preferred to pay more up front to avoid the doughnut hole?

The coverage gap was one of the most contentious elements of the 2003 legislation that created the new benefit. It ends federal payments for a person's drug purchases once an annual spending limit is reached, resuming them only after the beneficiary has spent thousands of dollars out of pocket.

Proponents saw the unusual setup as a way to provide some help to all beneficiaries, and substantial help to those with catastrophic drug costs, and yet not break the bank in a federal program that is expected to cost hundreds of billions of dollars over the next decade.

Precisely. They could have paid more up front and avoided the doughnut hole, but that would have been more unfair to those that did not need that many prescriptions. I think doctors prescribe a lot more than people really need. With too many drugs you get serious drug interactions.

Nine months into the program, as more and more seniors reach the threshold that puts them in the gap, many see it as a headache -- or worse.

Frances Acanfora, 65, had been paying $58 for a three-month supply of her five medications. But this month the retired school lunchroom aide learned that her next bill would be $1,294. She had entered the doughnut hole.

Without the program, she would have been paying $1294 all along.

"It's not my fault that I take this medicine," the Brooklyn resident said. "I've got to take it. And they make a limit. That's not fair."

Who made a limit? They paid for a lot of your drugs, but not all of them? That is not a limit.