Medicare: A,B,C,D!

(It truly is about learning A,B,C,D…..)

With the introduction of Medicare Part D in 2006, we had four letters to remember A,B,C,D. To most seniors and people eligible for Medicare, it’s still a confusion. All they know is: “I have Medicare”. In markets like south florida, most people are not aware of the 4 alphabets. They are under the impression that they are covered completely just because they have Medicare! I am focusing this discussion of Medicare Part D or prescription drug coverage within Medicare. Its upto us, the pharmacists, nurses, doctors to educate these patients.

Pharmacists report to us that, beginning of the year is hell for them…lol! First of all, most people have changed their insurances. Then, their copays are a big surprise. Someone who paid nothing last year gets to hear that his new copay is $950 or $2500! WOW! So, then, my pharmacist folks wrok hard to find these patients financial assistance through foundations so they can get their medications. And believe me, the processes aren’t just click of a button.

A lot of Marketting is done by third parties or insurers offering Medicare plans including C and D. A lot of education and TV ads are targeting this population so they understand and make good choices during open enrollment. But the question is: why do these people have to suffer during the “coverage gap” or “donut hole”?

Donut hole


To a lot of people who are actually Medicare D beneficiaries and even HCPs, it seems like “donut hole” has something to do with donuts… lol! But it’s not. Donut hole is a coverage gap when these patients use up a certain amount (around 3700) after which they pay about 25% of the cost of the medication. This is where problems come in.

The first hurdle is that these patients cannot be offered copay assistance from manufacturers as per Anti- kickback law, manufacturers cannot incentivize any patient to buy medications that are paid by Medicare or Medicaid or Tricare. So with this law in place, a lot of patients can not afford the copays. As a result, they chose either not to fill their prescription or cut their doses in half to make one month supply last 2 months. Unless, they know hardworking, dedicated pharmacists who can help them with financial assistance from foundations, they end up being NON-ADHERENT! But foundations do not necessarily have funds all the time. Its like “first come first” basis and after the funds run out, the other patients are left unfunded or untreated.

Non-adherence: costing big

Source: Fierce healthcare

Stats reveal that non-adherence is a big liability on health care costs. While the original purpose of instituting the gap was to limit the cost of the Part D program, it has resulted in unintentional consequences.

Read this article which details how does donut-hole affect adherence, health outcomes and thus health care costs.

Imagine, scenarios like a patient with grade 4 prostate cancer not been able to afford his medications. In such cases, patients refuse to get their refills and call doctors for going back to infusion chemo which is so much more aggressive and give undesirable side effects. In some cases, where chemo is not a possibility, patients just let go the medicine and hope to get funds from foundation whenever its available.

For some disease states like Psoriasis or Atopic dermatitis, there are rarely any funds available through foundations. So, patients are either forced to change treatments or come up with thousands of dollars as copay per month. Middle class usually suffers in these situations.

Luckily, PAP or “patient assistance programs” are available with most specialty brand medications. But again, patients are not aware of these. It falls on HCP team to coordinate the patient with the manufacturers. So, a question comes to my mind! Why are manufacturers allowed PAP but no copay assistance. This is what makes Medicare a bit confusing.

Sticky situations come in when the medication is a generic and the patient is in donut hole or has high deductible in the beginning of the year. Moreover, if foundations have no funds, then what? PAP doesn’t apply since its a generic. Copay is unaffordable and no funds available. Pharmacists become helpless in these situations. Non-adherence is imposed on these patients.


  • A thorough understanding of Medicare plans is needed to help patients chose the right plan for them.
  • All pharmacists and HCPs need to be proactive to find financial assistance to avoid Non-Adherence and thus, mortality.
  • Medicare needs some thought about deductibles, copays and Donut-hole.
  • More generics need to hit the market so costs become affordable.
  • Generic companies should also have PAP programs.

Published by Glucocious

The goal of “Pharmacist4U” blog channel “Over the Counter” is to create a social awareness of the several issues related to drugs, treatments and the healthcare system, overall. Our dream is to reach millions of patients out there who may have questions or concerns regarding their treatments, medications, costs or resources for help. We promise to find you the best solution or resolution through our blogs. If needed, a personal consultation can also be arranged to provide our readers with the help they need.

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