What Is The Donut Hole?

What Is The Donut Hole?

Beneficiaries of Medicare can get Medicare Part D prescription drugs through a separate Part D prescription drug policy or a Medicare Advantage Prescription Drug Policy. In both scenarios, Medicare Part D prescription drug insurance takes place in 4 phases: the deductible, initial insurance limit, the period without insurance and catastrophic insurance.

Insurance prior to the Medicare donut hole

Deductible: There are some policies for prescription drugs have a deductible period. That is, you pay the full cost of your prescription drugs until you have your Medicare Part D deductible or the Medicare Advantage Prescription drug for the calendar year.  Initial insurance limit: At this stage of your Medicare Part D insurance, you pay co insurance or co payment for each insured drug. The specific amount of co insurance or co payment is usually based on the level (or tier) of your medication. Lower levels are usually less expensive (and could include cheaper generics).

Once the total annual cost of the drugs, including the cost you have paid and the cost of your Medicare Prescription Drug Policy or Medicare Advantage Prescription Drug Policy, has reached a fixed amount ($ 3,750 in 2018), you will enter to the phase of insurance interruption, also referred to as donut hole. Not all policies have a insurance gap or a period without insurance.

Insurance gap, also referred to as “donut hole”

As mentioned above, this insurance phase does not start unless your policy has a deficit and you and your policy will spend $ 3,750 in 2018. At this stage, you have limited insurance for your insured drugs. In 2018, you will pay 35% of the cost of the Brand Drug Policy and 44% of the cost of the generic Policy until your annual drug cost is $ 5,000. The amounts and percentages required to reach the period without insurance may vary from one year to another. Once you reach the annual drug cost limit for the Donut Hole for the year, you move on to the next phase, called catastrophic insurance.

For more information about your costs in the Medicare insurance gap, also known as the “insurance gap,” visit Medicare website.  Insurance beyond the donut hole of Medicare  Catastrophic Insurance: If you paid $ 5,000 for out-of-pocket drug costs in 2018, you will only have to pay a small co insurance or co payment for insured drugs by the end of the year. There are some beneficiaries who do not spend $ 5,000 on medication costs, so they may never reach catastrophic insurance this year.

Restrictions on the lid with donut hole:

Note: The cost and insurance information only applies to drugs included in the Medicare Part D prescription drug policy or in the Medicare Advantage Prescription Drug Policy (or prescription drug list). If your medications are not listed in the formulary of your policy, this will usually not be insured unless you can obtain a formulary exception. Bear in mind that the forms can change at any time. Your Medicare policy will notify you when necessary.