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Making Sense of Medicare Part D - Out-of-Pocket Expenses
Copyright 2005 Jeremy Cockerill
A complete understanding of Medicare Part D Out-of-pocket
expenses is critical for all Medicare-eligible individuals in
order for them to maximize their savings and get the most out of
the program.
What are the Out-of-Pocket expenses associated with Medicare
Part D? On the Medicare.gov website "Out of Pocket costs" are
defined as "health care costs that you must pay on your own
because they are not covered by Medicare or other insurance."
The Out-of-Pocket (OOP) expenses associated with Medicare Part D
are basically any costs for an enrollee's medications that
Medicare will not cover and that they must pay for on their own.
These OOP expenses include the annual deductible, which ranges
from $0 - $250 depending on the individuals chosen plan, and any
other portion of their medication cost that they are required to
pay such as the drug cost co-payments. It is important to note
that an enrollee's monthly premium is not counted as an
Out-of-pocket expense. These premium payments are an additional
expense on top of the out-of-pocket expenses.
The majority of Medicare drug plans have a $250 annual
deductible and a 25% co-payment for all enrollee's drug costs
until they have reached $2250 in drug expenditures. Under this
scenario, at the $2250 expenditure point, enrollee's will have
$750 in Out-of-Pocket expenditures. How do we come up with the
figure of $750? This is calculated as such:
The $250 annual deductible + $500 (25% co-payment x $2000 of
drug expenditures) = $750
Individuals who have close to or exactly $2250 in annual drug
expenditures in 2006 will be the biggest winners of the Medicare
Prescription Drug plan. Based on the individual paying only $750
in OOP expenses and assuming that the individual payed the
national average monthly premium of $32.20, these individuals
save approximately 49% on their drug purchases. However, not
surprisingly, the majority of seniors do not fall in this
category and the savings drop off sharply when you spend more
than or less than the $2250.
For the millions of American seniors who will spend more than
$2250 on their drugs in 2006, this is where the Out-of-Pocket
expenses start to add up. Beyond the $2250 expenditure amount
you are responsible for paying for 100% of your drug cost until
you have spent $3600 out-of-pocket (called the Out of Pocket
Threshold). This means that between the annual drug expenditure
range of $2250 and $5100 you are 100% responsible for paying for
the cost of your medications.
How do we come up with the drug expenditure range of $2250 and
$5100? Here is the explanation:
When the Medicare Modernization Act was passed in 2003 it was
decided at that time that once people had spent $2250 on drug
expenditures they would then be 100% responsible for paying for
their drugs until they his a threshold of $3600 in drug
expenditures.
So between from $0 to $2250 there are $750 in out-of-pocket
expenses as we calculated earlier in this article.
$3600 OOP Threshold - $750 in OOP expenses at $2250 = $2850
remaining to reach the OOP Threshold.
Since after $2250 in
expenditures enrollees are 100% responsible
for their drug costs we can simply add the $2850 remaining to
reach the OOP Threshold to the $2250 in drug expenditures to get:
$2250 + $2850 = $5100
That is how we get the drug expenditure range of $2250 to $5100
in which enrollees are 100% responsible for their drug
expenditures.
This expenditure range is often called the "doughnut hole". It
is very important that Medicare eligible individuals are aware
of the doughnut hole because for the first few months of 2006
they may be budgeting based on only having to pay for 25% of
their drug purchases and then all of a sudden when they reach
$2250 in drug expenditures they are hit with responsibility of
paying for 100% of the drug cost. That is a huge and sudden
change in monthly expenditures.
It is also important that Medicare Part D enrollees are aware
that not all purchases are necessarily counted towards their
Out-of-Pocket expenditures. The following are examples of
purchases that will not be counted towards OOP expenses:
1. If a drug that an enrollee requires is not on the formulary
of covered drugs for their chosen drug plan (or if their plan
removes that drug from its formulary of covered drugs) that drug
purchase will not be counted towards their out of pocket
expenses and you are 100% responsible to pay for it. Purchasing
these non-formulary drugs, that the enrollee must pay full price
for, from Canada is an excellent alternative to paying high
prices at the local pharmacy. Individuals can save an average of
42% by purchasing these medications in Canada.
2. If an enrollee travels and buys their prescription drug at a
pharmacy that is not included in their drug plan's network of
pharmacies they are 100% responsible for the cost of the
medication and it will not be counted towards their OOP expenses.
3. If an enrollee currently has an insurance plan and they
utilize their insurance coverage to pay for their drug purchase,
the purchase will not be counted towards their OOP expenses.
4. If an enrollee purchases their medications from another
country that has low-cost, high-quality medications, such as
Canada, these purchases, unfortunately, will not be counted
towards their OOP expenses. However, these individuals may want
to explore this option when they reach the doughnut hole to help
them save even more money. In fact, if an individual spends more
than $2250 a year on medicines but less than $7050 a year,
buying their medicines from Canada once they hit the doughnut
hole is an excellent option for them.
Medicare eligible individuals' knowledge of Out-of-Pocket
expenses and what these expenses entail is crucial for them to
save as much as they possibly can with the Medicare Prescription
Drug plan.
About the author:
Jeremy Cockerill is a licensed pharmacist and the co-founder and
pharmacy manager of Universal Drugstore. Mr. Cockerill graduated
from the Faculty of Pharmacy at the University of Manitoba with
Honors in 1998. Mr. Cockerill is the recipient of the 2005
Manager of the Year award from the Manitoba Customer Contact
Association. http://www.universaldrugstore.com
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