Prescription Insurance Plan Coverage Gap

First off, I must state that paying for prescription medication can be daunting. At first your Rx plan covers most of the medications. You normally pay for the annual deductible for the plan itself, like I do through the AARP Medicare Rx Saver Plan ($295), then you pay the normal co-pays for the prescriptions....until you reach a certain spending limit which is actually your TROOP (true-out-of-pocket) expenses - that which you personally spent for deductibles and co-pays PLUS what your plan paid for the medication....now this usually means (in my case May 2009) that sometime in the near future you will be in what is called the "doughnut hole" or "coverage gap". This is a devastating plan. Don't ever tread those waters.

However, most people, like myself have really expensive medications like Abilify for my bipolar. This is like a $600 medication for 30 pills at 30mg each. That's a lot of money to spend if you have to spend it out of your own pocket without the help of the insurance that you currently have purchased to do the very thing you cannot do by yourself, which is to help defray the costs of the medication. Well...well...well... in the coverage gap - YOU, the consumer pays ALL the costs for the medications you are on. So, if you have any tier 1 medications, you are ok....I have 2, Wellbutrin and Ambien. Tier 2 medications, you have to pay full price, so these are maybe double, but certainly higher than tier one medications which tend to be less than $25 per script. I have several tier 3 meds, including Diazepam, Desoxyn, and Abilify - these meds are the most expensive on the list. So I am doomed to pay up to $4350/year for medications until you enter the catastrophic stage of your prescription plan. That's when the company usually pays nearly 100% of the medication cost, and you pay a small co-pay under $10 (usually less than $6 for me).

So - note this little tidbit in the back of your mind when you go to change your prescription drug plan in Nov-Dec of each year. Really do some cost comparing to see what is better for you in the long run. No one likes to pay for medication and certainly not 100% of it. I have a Medicare part D plan, and have to pay that premium AND my annual deductible AND my co-pays AND a minimum of $4350/year for the remainder of the year. This really sucks!

I have to go searching for ways to help me pay for this now, like going to churches and asking them if they have any monies in their pocket to help pay for my costs. They have helped in the past when I lived in Concord, NH. I was lucky then. I need to contact some other state and city agencies to see if there are any fund there too. In Concord, it was seemingly easy to show my expenses, income to the city's office where they help low income families and then I would get a check to help pay for these costs...but in Manchester, I don't know where to turn.

There are many ways to help defray these costs IF you look for them. Don't give up and certainly be wary of the plan you choose next time around to find either a lower out of pocket expenses ceiling than this one, boy I am gonna have a problem now.... either I find the money, or have to ask for different medications that reflect a tier 1 prescription for my insurance plan. Either way, I have some serious choices to make very soon, because I am running low on my Abilify and Desoxyn, which costs me about $900 total, for a 30 day supply.