How does Part D Rx coverage work in the Coverage Gap – Donut Hole?

Coverage gap (Medicare prescription drug coverage)—A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.  Your Guide to Rx Coverage #11109.

In 2020, you’ll pay no more than 25% for covered brand-name and generic drugs during the gap—the same percentage you pay from the time you meet the deductible (if your plan has one) until you reach the out-of-pocket spending limit Publication 11493

The “standard” Part D Rx coverage is spelled out below and shown in the Graphic below, it’s also explained in Your Guide to Rx Coverage #11109.

We can help you shop and see what Part D Rx  PDP or MAPD Medicare Advantage Plans that include Part D Rx, might work best for you.  See our instruction page for searching Part D plans.

  • Part D plans must cover at least the Part D standard benefit or its actuarial equivalent.

Simple Explanation Donut Hole 2020

2020 Donut Hole Graphic

2020 Part D Rx Donut Hole – Cost Sharing 
Click on link above or chart for a sharper clearer image

Part D Donut hole explained graph

Learn More ⇒

Medicare.Gov on better benefits through 2020.  Trump budget changes brings this to 2019.

Yes, this gets confusing and changes every year.  Be sure to double check by clicking the charts and publications on the right and your Evidence of Coverage to verify the information on the plan you have.

Unfortunately, you are not allowed to buy extra coverage to cover the gap or donut hole. 

However, Insurance Companies do  offer better than the minimum standard, Part D plans, than what is shown above.

Set a phone, Skype or Face to Face Meeting to review your quotes, needs & wants.

Resources & Links

Prescription Drug Plans – Part D Rx  (credible coverage), 

Your Guide to Rx Coverage Publication #11109  Page 15 Coverage Gap

Kaiser Family Foundation Overview  

Donut Hole Discounts  CA Healthline 2014

CA Health Advocates RX Medicare Drug Overview

Wikipedia on Part D  

How to get a formulary exception – if your Rx isn’t on the list

Check your actual policy – Evidence of Coverage for details.

If you are getting Extra Help paying Part D costs – with the LIS – Low Income Subsidy you won’t enter the coverage gap.

Email us if you have questions.

Steve’s explanation of the donut hole

Donut Hole - Coverage Gap
View Medicare Publication on closing the donut hole 11493it will close sooner  

Technical Research Resources

Obama Care PP/ACA on HR 4872 Section 1101 closing the Donut Hole

The cost of the drug is the AWP (Average wholesale price). the actual drug manufacturer sets the price and when member is in donut hole they usually won’t pay full price, they pay the AWP.

Medicare and You 2020 #10050  
Everything you want to know 

Medicare and you

Different Parts of Medicare 

A = Hospital
B = Doctor Visits - Out Patient
C = Medicare Advantage or Medi Gap
D = Part D Rx

Video

Understanding your Medicare Choices
Medi Gap vs Medicare Advantage

Topics

How to sign up for Parts A & B
Is  your test, service, or item covered?
Original Medicare Parts A & B
Medicare Advantage Plans & Part D Rx
Supplement Insurance (Medigap)
Low Income Help  LIS
Definitions

Enroll in Blue Cross

Enroll in Blue Shield 


Don't like computers?
Prefer a printed version be mailed to you?
Audio MP 3

Use our scheduler to Set a phone, Skype or Face to Face meeting
Intake Form - We can better prepare for the meeting

16 comments on “Donut Hole – Coverage Gap

    • Specialty tier drugs—defined by Medicare as drugs that cost more than $670 per month in 2019—are a particular concern for Part D enrollees in this context. Part D plans are allowed to charge between 25 percent and 33 percent coinsurance for specialty tier drugs before enrollees reach the coverage gap, where they pay 25 percent for all brands, followed by 5 percent coinsurance when total out-of-pocket spending exceeds an annual threshold ($5,100 in 2019). While specialty tier drugs are taken by a relatively small share of enrollees, spending on these drugs has increased over time and now accounts for over 20 percent of total Part D spending, up from about 6 to 7 percent before 2010.

      Medicare Part D enrollees not receiving low-income subsidies can expect to pay thousands of dollars out of pocket for a single specialty tier drug in 2019 (Figure 1). Median annual out-of-pocket costs in 2019 for 28 of the 30 studied specialty tier drugs range from $2,622 for Zepatier (for hepatitis C) to $16,551 for Idhifa (for leukemia), based on a full year of use; two of the 30 drugs are not covered by any plan in our analysis in 2019.

      With the now-complete closure of the Part D coverage gap for brand-name drugs, enrollees can expect to face lower annual out-of-pocket costs for selected specialty tier drugs below the catastrophic threshold in 2019 compared to 2016, but higher costs above—driven by an increase in underlying total costs between 2016 and 2019. For example, for Humira, for rheumatoid arthritis, median out-of-pocket costs below the catastrophic threshold decreased by $99 between 2016 and 2019 (from $3,155 to $3,057), while costs above the catastrophic threshold increased by $705 over these years (from $1,709 to $2,414)—and in total, expected annual out-of-pocket costs for Humira are $606 (12%) higher in 2019 than in 2016. Kff.org high drug cost chart

        • Part B covers certain drugs, like injections you get in a doctor’s office, certain oral cancer drugs, and drugs used with some types of durable medical equipment—like a nebulizer or external infusion pump.

          Under very limited circumstances, Part B covers certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare-approved amount for these covered drugs. Part B also covers the flu and pneumococcal shots. Generally, Medicare drug plans PDP cover other vaccines, like the shingles vaccine, needed to prevent illness.

          Note: Medicare Part A (Hospital Insurance) or Part B generally doesn’t cover self-administered drugs you get in an outpatient setting like in an emergency room, observation unit, surgery center, or pain clinic. Publication 11109 Page 12

          https://www.medicare.gov/coverage/prescription-drugs-outpatient

          • What about an infusion at my doctors office of remicade (Infliximab) for Crohn’s or IBS Irritable Bowel Syndrome?

            • Medicare covers most physician-administered drugs like REMICADE® under Medicare Part B. There are comprehensive published Part B coverage policies specific to REMICADE®. Copies of coverage policies (for example, local coverage determinations, or LCDs) are available on your regional Medicare Administrative Contractor’s, or MAC’s website.

              Medicare typically places few restrictions on REMICADE® coverage. However, some Medicare policies may limit coverage of REMICADE® to certain diagnoses, such as:

              Crohn’s disease
              Ulcerative colitis

              Rheumatoid arthritis
              Ankylosing spondylitis
              Psoriatic arthritis
              Plaque psoriasis
              You can check your regional MAC website for coverage policies for REMICADE® https://med.noridianmedicare.com/web/jea/topics/drugs-biologicals-injections or call Janssen CarePath at 877-CarePath (877-227-3728) for more assistance. https://www.janssencarepath.com/hcp/remicade/insurance-coverage/medicare

            • So Medicare Part B would have a $185 deductible, then Medicare pays 80%. Plan G would pay the other 20%.

              Use menu above to find Plan G Evidence of Coverage or Summary of Benefits

              Plan G

            • How is Part D coverage different from Part B coverage for certain drugs?

              It doesn’t cover most drugs you get at the pharmacy. You’ll need to join a prescription drug plan to get Medicare coverage for drugs for most chronic conditions, like high blood pressure.

              Part B covers certain drugs, like injections you get in a doctor’s office, certain oral cancer drugs, and drugs used with some types of durable medical equipment—like a nebulizer or external infusion pump. Under very limited circumstances, Part B covers certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare-approved amount for these covered drugs. Part B also covers the flu and pneumococcal shots. Generally, Medicare drug plans cover other vaccines, like the shingles vaccine, needed to prevent illness.

              Note:

              Medicare Part A (Hospital Insurance) or Part B generally doesn’t cover self-administered drugs you get in an outpatient setting like in an emergency room, observation unit, surgery center, or pain clinic. Your Medicare drug plan may cover these drugs under certain circumstances. You’ll likely need to pay out-of-pocket for the entire
              cost of these drugs and send in a claim to your drug plan for a refund of the portion not covered. Call your plan for more information. Also, visit Medicare.gov for more information on how Medicare covers self-administered drugs you get in a hospital outpatient setting. https://www.medicare.gov/Pubs/pdf/11109-Your-Guide-to-Medicare-Prescrip-Drug-Cov.pdf#page=12

              ■ Injectable and infused drugs: Medicare covers most injectable and infused drugs given by a licensed medical provider if the drug is considered reasonable and necessary for treatment and usually isn’t self-administered.

              CMS.gov # 11315

              I don’t see remicade or infliximab on https://www.medicare.gov/find-a-plan/questions/home.aspx

            • How Much Does Remicade Cost?

              A single dose of Remicade can cost from $1,300 to $2,500.

              The first step is determining insurance coverage for the infusion. Medicare does cover Remicade infusions. Most insurance companies require “pre-approval” for coverage. Therefore, the doctor’s office must explain to the insurance company what drug is being given, what other treatments have been tried, and why the new treatment is recommended (typically via a standard form). HMO coverage depends on the individual HMO and the particular agreement with the treating doctor. Any balance of the charges and/or co-pays should be understood prior to beginning treatment. https://www.emedicinehealth.com/remicade_for_rheumatoid_arthritis_treatment/article_em.htm

  1. Hi Steve,

    I’m new to Medicare and take several Rx for pain, asthma and a few other conditions. I heard that Part D makes one wait 6 months to a year to get coverage for the medications to cover a pre-existing condition. So, why should I bother getting coverage?

    ***Check our new page on Pre X and Prescriptions.

Leave a Reply

Your email address will not be published.

wp-puzzle.com logo