Judi L. Woods Agency Blog
The Coverage Gap or Donut Hole (or Doughnut Hole) has caused a considerable amount of confusion for many people and has even surprised seniors when they suddenly are required to pay the a higher price (or before 2011, the full price) of their prescription medications. The following brief over view is based on the 2011 Medicare Standard Benefit Plan Model. For more information, please click here to see Frequently Asked Questions (or FAQs) about the Donut Hole.
Quick Overview: This is a quick overview of the Donut Hole or Coverage Gap.
- According to the Medicare (or the Centers for Medicare and Medicaid Services, CMS), Standard or Model Medicare Part D prescription plan, the Donut Hole phase of your Medicare Part D coverage begins when your total retail drug costs reach $2840. (In past coverage years, some Medicare Part D plans have implemented a different Initial Coverage Limit and have begun the Donut Hole phase a little earlier - perhaps at a total retail drug spending of $1,800.)
- Please note, this $2840 is the total retail cost of the covered medications, not what you spend personally at the pharmacy. As a Medicare Part D beneficiary, you will pay only a portion of the $2840 and your Part D plan pays a portion. Your total retail cost of prescription medications is calculated from your Medicare Part D plan's negotiated retail drug price - and every Medicare Part D plan can have a different negotiated retail drug price. So it is possible that you may reach the Donut Hole a little earlier or later than someone else who uses the exact same prescription medications, but this other person has enrolled in a prescription drug plan from another Medicare Part D plan provider.
- As a note, in the CMS model Medicare Part D plan, a beneficiary; like yourself, pays the first $310 dollars as an initial deductible and then is responsible for paying 25% of the next $2530, for a total out of pocket medication costs (or true out of pocket costs (or TrOOP) ) of $942.5 (excluding your monthly plan premiums).
- Again, following the CMS Standard model Medicare Part D plan, when you reach the Donut Hole, your Medicare Part D plan will have paid the difference between the negotiated retail cost of all your drug purchases and your out of pocket cost or $1897.5.
- However, most people simply say that you enter the Donut Hole phase of your Medicare Part D plan at the end of your Initial Coverage phase or when your reach your Medicare Part D plan's Initial Coverage Limit (again, around $2840).
- With Changes in the Medicare law, a $250 Donut Hole Rebate program was implemented in 2010. Anyone reaching the 2010 Donut Hole would be automatically mailed a check for $250. Click here to read some frequently asked questions about the 2010 Donut Hole rebate.
- The 2011 Donut Hole marks the beginning of an effort at closing the Donut Hole. In 2011, anyone reaching the Donut Hole will receive a 50% (fifty percent) discount on brand name formulary drugs and a 7% (seven percent) discount on all generic formulary medications. Click here if you would like to read more about the Donut Hole drug discount program.
- Still have a question on the Donut Hole basics or did we miss something about the Donut Hole? Click here and let us know.
Please note there are some changes each year but this info is as of 2011 and there are few changes for 2012 so please ask me for details when we speak.