Medicare Part D Gap or Donut Hole

donut-hole-insurance-plansThe Medicare Part D prescription drug Coverage Gap or Donut Hole, is the phase of your Medicare Part D benefit where there is a significant gap in your prescription drug coverage. During this phase, you have to pay more for your name brand medications, until you reach the catastrophic coverage phase where you will then have very small copays for those same name brand drugs.

When your total RETAIL drug costs reach $2,960 in 2015 ($3,310 in 2016) you fall into the Medicare Part D Gap or Donut Hole. Once you’ve reached that retail limit you begin paying higher copays for that same name brand medication until you reach the catastrophic coverage phase (when your total out-of-pocket costs, including any annual deductible, any and all copayments and or coinsurance, reach $4700).

How does the Affordable Care Act affect Medicare’s Coverage Gap (Donut Hole)?

Until 2020, when the coverage gap ends, you’ll pay less and less for your medications.

  • In 2015, you’ll pay 45% for brand-name drugs and 65% for generic drugs.
  • In 2016, you’ll pay 45% for brand-name drugs and 58% for generic drugs.
  • In 2017, you’ll pay 40% for brand-name drugs and 51% for generic drugs.
  • In 2018, you’ll pay 35% for brand-name drugs and 44% for generic drugs.
  • In 2019, you’ll pay 30% for brand-name drugs and 37% for generic drugs.
  • In 2020, you’ll pay 25% for brand-name drugs and 25% for generic drugs.

How can I delay reaching the Medicare Part D Gap or Donut Hole?

There are a number of things you can do to lower your drug costs all year long and delay reaching the coverage gap:

Talk to your doctor about using lower-cost generics that are right for you.

  • Shop around to see if any other local pharmacies offer your medication at a lower rate.
  • Buy your maintenance medications (medications that you take every month) from your plan’s mail-order pharmacy. Mail-order pharmacies typically provide a three-month supply of medication for about the same amount as a two-month supply at retail pharmacies.
  • Use the preferred pharmacy if your drug plan has preferred and non-preferred pharmacies in its network. Your copayments will be lower if you use the preferred pharmacy.
  • Look for programs that offer assistance. Some drug manufacturers offer discounts or special programs for certain drugs.

If you do reach the coverage gap, you may want to discuss the possibility of using a different, generic or lower cost medication. Check with your doctor and work with him/her to find out of there is an alternative medication that might work for you.

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