Say Goodbye to the Donut Hole
For all the Medicare beneficiaries who find themselves falling into the Medicare’s prescription drug coverage Part D donut hole (coverage gap), the Bipartisan Budget Act of 2018 is here to help. The Act speeds up the closing the coverage gap and offers prescription cost relief in 2019.
Currently, Medicare beneficiaries who’s prescription costs have reached $3,750 fall into the Part D coverage gap. It is important to note that the $3,750 is the retail cost of the prescriptions not what the beneficiary has paid towards them.
Meaning, they’re required to pay $5,000 for prescribed drugs out of their own pocket. Unlike the $3,750 to fall into the gap, the $5,000 represents the amount the Medicare beneficiary has spent out of their own pocket.
When the $5,000 threshold is met, Medicare beneficiaries exit the donut hole and catastrophic coverage kicks in. At that point, 95% of drug costs are covered for the remainder of the year. This is great news for Medicare beneficiaries who pay high out of pocket costs for their brand name medications.
Closing the Medicare Part D Donut Hole in 2019
Since the Affordable Care Act was passed in 2010, the donut hole has been slowly closing. By 2020, beneficiaries are expected to only pay 25% of their brand name drug costs while in the donut hole.
Now, enrollees won’t have to wait until 2020. Instead, the gap is closing beginning of 2019. Beneficiaries no longer have to choose between expensive medications that work vs medications that cost less, but aren’t as beneficial.
How the Donut Hole Coverage Gap Works
Medicare beneficiaries pay their deductible if applicable, and their copays(coinsurance) until the costs reach $3,750 for their prescriptions medications. Once a beneficiary drug cost exceeds $3,750 , they “fall” into the donut hole(coverage gap). Beneficiaries become responsible for paying up to $5,000 for their prescription drugs.
After $5,000 is paid out of pocket, the beneficiary reaches a what is referred to as catastrophic coverage phase. While in the catastrophic coverage phase, Medicare beneficiaries pay 5% of the cost of their prescription drugs for the remainder of the year.
Cost for Generic and Brand Name Medications while in the Donut Hole
To clarify, the “donut hole” still exists, but pharmaceutical companies will now be required to pick up more of the tab. Thus, resulting in lower out of pocket expenses and closing the gap faster. The Bipartisan Budget Act of 2018 requires pharmaceutical companies to offer the same discounts to Medicare beneficiaries as they offer insurance providers and pharmacies.
Currently in 2018, once beneficiaries reach the donut hole, they’re responsible for 44% of the cost of generic drugs and 35% of brand name drugs.
Changes to the 2019 Medicare Part D Donut Hole
- Brand name drugs will be covered at 75%, reducing your shared cost to 25%.
- Generic drugs will be covered at 63%, reducing your shared costs to 37%.
- Standard initial deductibles are projected to increase from $405 to $415 a month.
- Your initial coverage limit is projected to increase from $3,750 to $3,820.
- The donut hole TrOOP is projected to increase to $5,100 from $5,000. However you are paying less money out of pocket to reach the $5,100.
- After you reach the $5,100, you become eligible for catastrophic coverage. At that point both your generic and brand drug purchases will be covered at 95%.
Additional Information to Know About the 2019 Medicare Part D Donut Hole
- Beneficiaries enrolled in the Extra Help program are not eligible for these discounts.
- Medicare sends a monthly Explanation of Benefits (EOB) that will indicate how much has been spent on generic and brand prescription drugs.
Compare Medicare Prescription Drug Plan Options
To compare prescription drug plans, you can use this Part D plan finder.