How does Part D Rx coverage work in the Coverage Gap – Donut Hole?
The “standard” Part D Rx coverage works like this for 2016 – 2017 Graphic, as explained in Medicare & You 10050 on Page 111. 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.
First there is a deductible of $360.
Second, you have Initial Coverage and pay $1,098 in Drug – RX costs – 75% Drug Plan – 25% you.
Fourth, after you pay out $4,850 you enter Catastrophic Coverage and you pay only 5% or $6.60 for a brand name and $2.95 for generic. Learn More ⇒ Medicare.Gov on better benefits through 2020
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. Click here to enter your medications and comparison shop. When you use HealthCompare.com, which includes NATIONWIDE Quotes, we get a finder’s fee, but are not your agent.
In CA we suggest that you use our affiliate Blue Cross & Blue Shield websites where you can enter the Rx you take and get a print out of what your costs will be for the year.
Resources & Links
Your Guide to Rx Coverage Publication #11109 Page 15 Coverage Gap
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.
Call 310.519.1335 or email us if you have questions.
Technical Research Resources
Obama Care PPACA on 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.
Trying to get the lowest costs in and around the donut hole. We took Humira as an example and used Medicare.Gov (be careful and be sure to double check on the actual insurance company website – also, if you don’t get coverage from a company we represent – we will NOT be your agent and cannot contact the Insurance Company on your behalf!) Here’s a pdf of the example or click on thumbnail at left to see a screen shot.
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