Medicare’s prescription drug ‘doughnut hole’: what you should know

Dear Toni: I turn 65 in May and am covered by my wife’s employer group health insurance. I’m fighting stage 3 kidney cancer, and the prognosis is good since I am participating in a clinical trial for a new cancer medication. It costs over $20,000 per month, but with this trial, I am paying $0 for a drug that is curing my cancer.

I am not planning to enroll in Medicare until my wife retires when she turns 65 in two years. I am concerned about Medicare’s prescription drug plan and Medicare’s doughnut hole. Can you please explain Medicare and clinical trials and what I should do? — Matthew

Dear Matthew: You are wise to remain on your wife’s employer benefits because you both can enroll in Medicare Parts A and B when your wife retires in two years. At that time, you will be eligible for a special enrollment period, avoiding the Medicare Part B penalty, and will be able to enroll in a Medicare Part D prescription drug plan.

Let’s go over your clinical trial drug and if you would go in the so-called doughnut hole.

The Toni Says Medicare team advises people to enroll in the Medicare Part D plan that covers all of their prescriptions — even if their most expensive drug is covered by a clinical trial program and costs them nothing — because eventually it may no longer be available through the trial. If that happens, they will have the expensive doughnut hole experience.

Matthew, you would go into the doughnut hole the second you order an expensive prescription such as the one you are currently taking, which would cost more than $20,000 per month if you were not enrolled in a clinical trial. When you are ready to enroll in Medicare, search the Medicare.gov prescription drug website for the Part D plan that best meets your Medicare and financial needs.

The Medicare Part D prescription drug monthly cost is usually outrageous when cancer prescriptions are included because brand-name cancer prescriptions are usually a tier 5 specialty drug. So, the Part D prescription drug plan cost goes in and out of the doughnut hole, and into Medicare Part D’s catastrophic coverage, immediately.

If you are not enrolled in a Part D plan that covers the expensive prescriptions, then you will pay 100 percent out of pocket for the prescriptions that are not covered. (Even if you have a plan that covers your expensive medications, you should check it again during the annual enrollment period, Oct. 15-Dec. 7, as it can change.)

Enrolling in Medicare Part B for the first time when your wife retires is a good option. Both of you will qualify for the Medicare supplement during your six-month open enrollment period without having to answer health underwriting questions.

Original Medicare and your Medicare supplement will work together with your clinical trial program to cover your medical needs. Original Medicare covers the routine costs of qualifying clinical trials. Your Medicare supplement plans will then pay the out-of-pocket costs that original Medicare does not pay for expenses that meet Medicare qualifications.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.