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Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
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The following steps help to maximize use of Medicare Part D. They are described in the other sections of this article.

Find Out If There Is Help To Pay For The Insured's Portion Of Costs

If You Have Limited Income And Assets

Find out if you qualify for:

  • Medicaid (which includes drug coverage)
  • The Extra Help Program to help pay for the cost of Medicare Part D coverage.
  • State drug assistance programs (including ADAP if you have HIV)

Look for Insurance Coverage

You cannot purchase separate insurance to fill gaps in Part D coverage. However, there are a few options:

  • Some Medicare Part D plans offer coverage without a donut hole. They tend to be more expensive than other plans but may be worth it if your drugs are expensive.
  • A spouse's insurance.
  • An employer plan that offers a drug plan that coordinates with Medicare Part D. Unlike state assistance programs, any payments an employer makes toward your drugs don't count toward your Catastrophic Limit.

How To Make Coverage Last Longer Before Reaching The Doughnut Hole

  • Only purchase drugs from pharmacies in your Plan's network.
  • Ask your doctor to prescribe drugs on the lowest tier of the Plan's Formulary when possible. This saves on your co-pay and the total cost of the drug.
  • Save money when purchasing drugs you take on a consistent basis by filling prescriptions on a 90 day basis. To find a plan which permits purchase of a 90 day supply go to offsite link. In "Prescription Drug Choices", click on  "Find & Compare Plans that Cover Drugs", click on "Find & Compare Plans". Ultimately click on "Only show me plans that allow me to use mail order pharmacies."  Once you identify a few plans in which you are interested, call to confirm that the plan permits 90 day orders.
  • AARP has an interactive online tool to help postpone or avoid the doughnut hole. The tool requests your health plan, medications and zip. You get a customized report which tells you how long your coverage will last before you fall into the hole. The tool automatically lists less expensive medication alternatives. It also allows you to print a letter to give to your doctors about your medication options. See: offsite link
  • Use other techniques to save money when purchasing drugs. See Drugs: How To Save Money When Buying Or Using offsite link

To Learn More

When And How To Ask For An Exception (Appeal)

If any of the following situations occur, you can ask your Plan for an Exception if:

  • A drug you need isn't on a formulary
  • If the Plan raises the amount you pay for a drug.
  • If a drug you need is subject to a high copay.
  • Your Plan replaces a brand name drug you are taking with a generic version and only the brand name will work for you.
  • Your plan requires that you take another drug first.

Before asking for the Exception, speak with your doctor to find out if another drug on the Formulary will work for you. If so, change your prescription to the covered drug.

If not, ask your doctor to request an exception. Your doctor has the medical knowledge needed to justify a request about the effectiveness of a drug. Even if the question is financial, a significant factor in the request is that another drug on the formulary won't work as well for you.

If your doctor won't contact the plan for you, if the question is about medical necessity, at least get a written statement from your doctor about the need for an exception. If you're not comfortable negotiating, ask a seasoned friend or family member to contact the Plan for you.

  • Follow the Plan's rules.
  • Ask your doctor to call or write the Plan. If he or she won't, ask for a letter explaining why this is the only drug that works for your particular situation.
  • The insurer must respond within 72 hours (24 hours if medically necessary.) If your Plan denies an exception request, you can always appeal. The denial letter from your Plan will explain how to appeal, and the time limit for the appeal.
  • Once you go through the Plan's appeal process, you are entitled to a review by:
  • An Independent Review Entity (formerly "Independent Contractor").
  • Then, an Administrative Law Judge.
  • Then by the judicial system if you claim meets minimum dollar amounts.

It is not advisable to appeal on your own. The appeal can involve complex medical questions. An excellent, free, source of help is the Medicare Rights Center, offsite link, Tel.: (Consumer Hotline): 800.333.4114 9AM -- 6PM ET

You cannot ask for an exception for drugs which are specifically excluded from coverage, such as weight loss drugs.

Adjust The Doughnut Hole To Fit Your Needs

If the doughnut hole cost you a lot of money this year and you expect a similar pattern of drug purchases next year: Consider purchasing a plan which will cost you a higher premium but which will either increase the lower limit at which the doughnut hole starts, or eliminate it entirely.

How To Save Money While In The Doughnut Hole

How To Avoid Unnecessary Problems When Picking Up Drugs From A Pharmacy

When you go to a pharmacy, bring your Medicare drug card. If you don't have a card, bring written documentation from the insurer and the insurer's contact information as well as your Medicare or Medicaid card and a photo ID. (If the problem can't be resolved, ask the pharmacist for a supply for a few days while the situation is being resolved. Medicare will reimburse pharmacists for up to 30 days' worth.

If you are going to switch plans try to do it during the first two weeks of the month.Signing up early in the month gives the plan time to issue your ID card and get your details into the pharmacy computer system before coverage starts on the first day of the following month.