Mrs. Anderson reaches the coverage gap in her Medicare drug plan. She goes to her pharmacy to fill a prescription for a covered brand-name drug. The price for the drug is $60, and there’s a $2 dispensing fee that gets added to the cost. Mrs. Anderson will pay 45% of the plan’s cost for the drug ($60 x .45 = $27) plus 45% of the cost of the dispensing fee ($2 x .45 = $0.90), or a total of $27.90, for her prescription. $57.90 will be counted as out-of-pocket spending and will help Mrs. Anderson get out of the coverage gap because both the amount that Mrs. Anderson pays ($27.90) plus the manufacturer discount payment ($30.00) count as out-of-pocket spending. The remaining $4.10, which is 5% of the drug cost and 55% of the dispensing fee paid by the drug plan, isn’t counted toward Mrs. Anderson’s out-of-pocket spending.
Understanding the Medicare Part D Donut Hole
Once you and your Part D drug plan have spent $2,840 for covered drugs, you will be in the donut hole. Previously, you had to pay the full cost of your prescription drugs while in the donut hole. However, in 2011, you get a 50% discount on covered brand-name prescription medications. The donut hole continues until your total out-of-pocket cost reaches $4,550. This annual out-of-pocket spending amount includes your yearly deductible, copayment, and coinsurance amounts.
Medicare Part D coverage gap
The Medicare Part D coverage gap (informally known as the Medicare donut hole) is a period of consumer payment for prescription medication costs which lies between the initial coverage limit and the catastrophic-coverage threshold, when the consumer is a member of a Medicare Part D prescription-drug program administered by the United States federal government. The gap is reached after shared insurer payment – consumer payment for all covered prescription drugs reaches a government-set amount, and is left only after the consumer has paid full, unshared costs of an additional amount for the same prescriptions. Upon entering the gap, the prescription payments to date are re-set to $0 and continue until the maximum amount of the gap is reached: copayments made by the consumer up to the point of entering the gap are specifically *not* counted toward payment of the costs accruing while in the gap.
How does this Donut Hole really work?
I use medications not covered by my Medicare Part D plan or sometimes I buy my medications from outside of the country (for instance, in Canada or Mexico). Are these prescription drug expenses included in the $3310 or any other Part D calculation? No. Any medications not included on your Medicare Part D plan’s formulary or drug list (also known as: out of formulary drugs) or drugs that you purchased outside of the United States fall outside of your Medicare Part D coverage and are not included in the $3310 or any other Part D calculation. If you use a medication that is not included on your formulary, you can ask your Medicare Part D plan for a formulary exception or coverage determination, whereby your non-formulary drug would be included on your own personal formulary. If your Medicare Part D plan denies your request for a coverage determination, you can appeal the denial – several times. Be sure to ask your Medicare Part D plan for details on the formulary exception and appeals process.
Medicare drug costs to fall in 2014, but donut hole widens
Before passage of the ACA, seniors in the gap paid 100 percent of all drug costs. Now, they pay 50 percent out-of-pocket for brand-name drugs, with the rest made up by insurers and discounts from pharmaceutical manufacturers. For generics, they pay 79 percent. Enrollees’ out-of-pocket burden for brand-name and generic drugs will gradually fall to 25 percent by 2020 – the same percentage applied for standard coverage.
Donut Hole, Medicare Prescription Drug
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.