It’s important to continue to stick with your prescription drug plan and pharmacy once you hit the coverage gap. If you have a Medicare prescription drug plan that already includes coverage in the gap, you may get a discount after your plan’s coverage has been applied to the price of the drug. The discount for brand-name drugs will apply to the remaining amount that you owe.
Closing the Medicare Part D Donut Hole
The Affordable Care Act (ACA) includes important improvements to Medicare prescription drug coverage (Part D) such as reducing expenses for seniors in the donut hole now and eliminating the gap altogether by 2020. Seniors receive additional savings each year on their prescription drugs until the donut hole is closed. The ACA also provides additional assistance for low-income beneficiaries. Since passage of the ACA in 2010, more than 7.9 million people with Medicare have saved over $9.9 billion on prescription drugs.
Medicare Part D Donut Hole – Prescription Drug Coverage Gap
Most Medicare Part D plans have a coverage gap, sometimes called the Medicare donut hole. This means that after you and your Medicare drug plan have spent a certain amount of money for covered prescription drugs, you then have to pay all costs out-of-pocket for the drugs, up to a certain limit. The yearly deductible, co-insurance, or co-payments, and what you pay while in the coverage gap, all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium.
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.
What on Earth is the Donut Hole? A Brief Explanation of Medicare Part D and the “Donut Hole” » The NeedyMeds Blog
In 2013, you get out of the coverage gap when you have paid $4,750 out-of-pocket for covered drugs since the start of the year. When you reach this out-of-pocket limit, you get catastrophic coverage. The costs that help you reach catastrophic coverage include what you spent on drugs while in the donut hole and most of the discount on brand-name drugs you received in the coverage gap. If someone else pays for your drugs on your behalf, this will also count toward getting you out of the coverage gap. This includes drug costs paid for you by family members, most charities, State Pharmaceutical Assistance Programs, AIDS Drug Assistance Programs and the Indian Health Service. You continue to pay your drug plan’s monthly premium during the gap, but the premium does not count toward the $4,750 out-of-pocket limit. The amount your drug plan paid for your drugs in your initial coverage period also does not count.
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.
Costs in the coverage gap
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.
www.Q1Medicare.com Your Source for Medicare Part D Plan Information
Looking for a place to get started? Here is an overview of the Medicare Part D prescription drug and Medicare Advantage programs: Medicare Part D prescription drug plans (or PDPs) provide insurance coverage for your prescription drugs. Medicare Advantage plans (MAs or MA-PDs) provide your Medicare Part A coverage (In-patient and Hospitalization) and your Medicare Part B coverage (Doctors visits and Out-Patient care) – and maybe even Medicare prescription drug coverage. Medicare Part D plans and Medicare Advantage plans are both voluntary programs and you are not required to join a plan. But you may be subject to a late-enrollment penalty if you decide to join a prescription drug plan sometime after your initial enrollment period has ended. Medicare Part D plans and Medicare Advantage plans are regulated by the Centers for Medicare and Medicaid Services (CMS or Medicare) and implemented by private insurance companies (such as Aetna, Humana, and United HealthCare). If you decide to enroll in a Medicare Part D plan or Medicare Advantage plan, you will find that, like any insurance, you pay a monthly premium. The monthly premiums for a Medicare Part D PDP can range from under $20 to over $130 dollars. The monthly premiums for a Medicare Advantage plan with (MA-PD) or without (MA) prescription coverage can range from $0 (no kidding) to well over $100. Medicare Part D and Medicare Advantage plans may have an initial deductible, co-payments or co-insurance, and some Donut Hole (Doughnut Hole) or Gap coverage (you can find more on these topics in our Glossary). When you enroll in a Medicare Part D prescription drug plan or a Medicare Advantage plan that offers prescription coverage, you should find that your prescription medication costs are reduced. The amount of savings depends on the Medicare plan you select. If you wish to learn more, you can click on this link to view all of the Medicare Part D plans in your State