What is the Medicare Part D donut hole?

The Medicare Part D “donut hole” is a temporary coverage gap in how much a Medicare prescription drug plan will pay for your prescription drug costs. Starting in 2020, Medicare Part D plan beneficiaries pay 25 percent of their brand name and generic drug costs while they’re in the coverage gap.

What happens in the donut hole coverage gap in 2020?

Once you enter the donut hole in 2020, your Part D plan’s coverage becomes more limited. In 2020, you’ll pay no more than 25 percent of the price for brand name drugs and generic drugs while you’re in the donut hole.

What happens when the donut hold goes away in 2020?

Once you reach the $6,350 threshold in 2020, you enter the final phase of Part D coverage. This is called catastrophic coverage. During the catastrophic coverage phase, you only pay a small coinsurance or copayment for your covered prescription drugs for the remainder of the year.

Part D

Prescription Opioids: What Medicare Beneficiaries Need To Know

by Lisa Eramo, MA
February 22, 2021

Medicare Part D can cover opioids to help you manage pain in the short-term, but opioids can be highly addictive when used in the long-term. Understanding how to protect yourself can minimize your risk of developing a dependence or overdosing on these highly-addictive drugs.

It can happen unexpectedly. One minute you’re taking a pill to relieve some minor back pain. The next minute, you’re addicted, or worse, you overdose accidentally.

Approximately 5,000 Medicare Part D beneficiaries per month suffered an opioid overdose during the first eight months of 2020, according to the Office of Inspector General (OIG). The OIG is charged with providing oversight to Health and Human Services programs, including Medicare and Medicaid.

In what has now been dubbed an ‘opioid epidemic’ in the United States, more than 130 people die every day from opioid-related drug overdoses. More than 80% of drug overdose deaths involve opioids.

Addressing this problem requires educating yourself about prevention and knowing what to do if you become addicted. Here are several important questions to consider.

What are opioids, and why are they dangerous?

Opioids are a type of pain-relieving drug. They attach to opioid receptors in your brain cells, causing those cells to release signals that mute your perception of pain and increase your feelings of pleasure.

Although these medications are highly effective in certain scenarios (e.g., after a major operation or severe trauma), they become dangerous when you take them for too long. You can become dependent on them, meaning you experience physical and psychological symptoms if you don’t take the drug. When this happens, you can have a compulsive need for the drug even despite its harmful effect on your life.

The most common drugs involved in prescription opioid overdose deaths are Methadone, Oxycodone, and Hydrocodone. However, many other prescription opioids can be highly addictive and can cause overdoses. Examples of these drugs include Morphine, Codeine, Hydromorphone, Meperidine and Tramadol.
Fentanyl, another prescription opioid, is a synthetic opioid pain reliever that is 50 to 100 times more potent than morphine and can also be highly addictive.
Heroin is an illegal opioid processed from morphine and extracted from certain poppy plants.

Why is opioid dependence and addiction dangerous during COVID-19?

There is evidence that substance abuse disorders – particularly opioid abuse – are linked to COVID-19 susceptibility. This could be because the lungs and cardiovascular system are often compromised in individuals who have a substance abuse disorder. In addition, African Americans with an opioid use disorder are more than four times more likely to develop COVID-19 compared to White Americans.

Other risk factors for COVID-19 (e.g., hypertension, diabetes, cardiovascular disease, and renal diseases) are also more prevalent among African Americans with an opioid use disorder.

What can I expect if my doctor prescribes an opioid?

If this is the first time a doctor has prescribed an opioid for you, you may be limited to a seven-day supply or less to decrease the likelihood that you’ll become dependent on the drug.

If your doctor continues to prescribe it, your Medicare drug plan will likely continue to monitor your use of the opioid to ensure that it’s safe. This is especially true if you get opioids from multiple doctors or pharmacies or if you use opioids and benzodiazepines (a type of drug that depresses your central nervous system) at the same time.

What can I do to protect myself when taking opioids?

There are several steps you can take to prevent opioid addiction and overdose.

First, know your options for pain management. Although opioids can help you in the short-term, ask your doctor about other ways to manage your pain effectively such as non-opioid pain relievers, physical therapy and exercise, cognitive behavioral therapy and certain antidepressants and anticonvulsants.
Second, take the proper dose as prescribed.
Third, talk with your doctor about having naloxone at home. Naloxone is a drug that your doctor may prescribe as a safety measure to rapidly reverse the effects of an opioid overdose.

How do I know whether I’m addicted to opioids or overdosed on them?

You might be addicted to opioids if you exhibit any of these signs:

You’re unable to cut down or stop using opioids
You make mistakes at school or at work because of opioids
Your relationships are suffering because of opioid use
You need larger amounts of opioids to feel good
You have strong cravings for opioids
You overdose on opioids

Signs of an opioid overdose include constricted pupils, loss of consciousness, shallow breathing, choking, limp body, or cold/pale skin. If you suspect an opioid overdose, call 911 immediately.

What should I do if I think I’m addicted to opioids?

You have several options. One is Medication-Assisted Treatment (MAT). MAT combines medication with counseling and behavioral therapy to help you recover, and it may or may not be the right choice depending on your specific needs.

Another option is residential-based or hospital-based treatments. You can easily find a treatment facility confidentially and anonymously. There are also plenty of books, support groups, and other resources available to help you overcome your addiction.

Talking with your primary care physician is a good first step.

This article is for informational purposes only. It is not healthcare advice, treatment or diagnosis. Speak to your doctor or healthcare provider about your specific healthcare needs, including your prescription medications. Only take medication as directed by your doctor.