Medicare Donut Hole

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The Medicare Donut Hole is the coverage gap part of Part D. During this period; the beneficiary will have a temporary limit on their prescription drug coverage.

So, after spending a particular amount on a drug plan for prescription drugs, you’re responsible for costs out-of-pocket for drugs. Then you have responsibility for costs up to a particular out-of-pocket limit.

Some of the things that count towards the out-of-pocket limit include co-payments, coinsurance, the yearly deductible, and what you pay during the coverage gap.

Medicare Donut Hole Coverage Explanation

The best way to explain the Medicare Donut Hole is that once your total prescription drug costs, your deductible, what your insurer has paid, and your co-pays exceeds a particular amount, you’ll enter the donut hole gap.

During the gap period, you must pay a certain percentage of the total cost of both brand-name and generic drugs. Medicare Donut Hole coverage gets a certain percentage of the discounts on brand-name medicines by the drug manufacturers while the federal government pays the rest.

Like most things pertaining to Medicare, 2019 changes to the donut hole have been made.

Status of My Medicare Donut Hole Insurance Coverage Gap

The monthly statements you obtain from your plan provider should show you where you stand regarding your Medicare Donut Hole insurance coverage gap.

Whether you’re almost entering the gap or you’re already in it, knowing how much more you’re required to spend on your medicines before you qualify for the catastrophic coverage is a must.

How Can I Avoid the Medicare Donut Hole

If brand name drugs are a requirement for you, avoiding the donut hole could be near impossible. However, if you’re flexible in using generics drugs, prescription costs could be substantially lower.

You can prevent the coverage gap if:

  • The cost of your drugs for the year does not go beyond a certain amount
  • You have additional coverage from your employer or union benefits which covers part or all costs
  • Medicare drug plan covers medicine while in the gap. This is usually for a higher premium. Costs for the additional coverage vary from plan to plan

Those that qualify for extra help, which is a low-income subsidy. The subsidy is a federal program which helps individuals with low-income pay for the Medicare Part D costs; like deductible, copayments/coinsurance, and premiums. You can apply for this program through the Medicaid department or through the Social Security Administration.

If you qualify for this Help, you won’t enter the “gap.”

How Do I Get Out of the Medicare Donut Hole Gap

You’ll get out of the Medicare Donut Hole gap when your out-of-pocket payments during the beginning of the year [co-pays and deductibles] and anything you paid for medicines during the gap period reaches a certain amount.

Note that, the manufacturers’ contribution to the brand-name medicines also count towards your limit.

However, the amount contributed by the government does not make for the limit. Once you reach the limit, catastrophic drug coverage will kick in automatically, and your policy will settle 95 percent of the remaining costs until the year-end. This cycle repeats every calendar year.

How Do I Get My Prescriptions During the Gap Period

You can purchase prescriptions at your normal pharmacy during the donut hole.

Your insurer will track your costs so that they can be able to count toward your out-of-pocket limit. You can also get your drugs elsewhere which are less expensive than what your plan charges. Only medicines bought at pharmacies within the network of your plan contribute to the Medicare Donut Hole limits.

When you buy over the counter medicine, that doesn’t count towards your donut hole costs.

Medicare Donut Hole Prescription Assistance: Extra Help

Ask your doctor if any other medicine on your plan’s prescription would be as effective for your condition as the ones you’re currently using. Using lower-cost drugs, like generics or similar drugs but older brand-names will substantially lower your costs.

It pays to have Medicare Donut Hole prescription assistance additional insurance like Extra Help or a state pharmacy assistance plan that can pay a portion or all your costs while in the gap. If you don’t have additional Medicare Donut Hole coverage help, you can consider non-insurance sources of help like:

  • Lower-cost drugs from countries like Canada
  • Free or low-cost medicines supplied by charities, patients’ organizations, or local medical clinics.
  • Low-cost or Free medicines from Medicare Donut Hole assistance programs, managed by pharmaceutical manufacturers

Compare Medicare Part D Insurance Plans Online

To compare Medicare Part D insurance plans online today, you can use the Medicare Plan Tool Finder.  Fill out the rating form on our site so that we can give you different rates as charged by various insurance providers.

Although, the fastest and easiest way to get ideal coverage is by calling a broker at the number above.