2019 Part D Graphic
2019 Part D Graphic – click to enlarge  

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.

The “standard” Part D Rx coverage is spelled out below and shown in the    Graphic, 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.

 

  • For 2019, the standard benefit requires the beneficiary to pay:
    • $415 deductible
    • 25% of prescription drug costs between $415 and $3,820 
    • Part of the costs in the “Coverage GapGraphic
      • After total spending on drugs by the beneficiary, by certain subsidy programs and by the plan reaches $3,820 the beneficiary pays for 37% of generic drug costs and 25% of brand name drug undiscounted costs (drug manufacturers provide a 50% discount on brand name drugs).
        • The amount beneficiaries pay while in the coverage gap decreases by a small percentage each year until 2019 when they will be responsible for only 25% of brand and generic drug costs.
    • Nominal costs under catastrophic coverage:
      • Once beneficiary expenditures (including drug manufacturer discounts) reach a total of $5,100, the beneficiary is through the coverage gap and reaches catastrophic coverage. On any future prescriptions the beneficiary pays either a co-pay of $3.40 for generic drugs or $8.50 for brand name drugs or a co-insurance of 5%, whichever is greater. 
      •  
  • See graphs below for sources and a different way of looking at it.  The real issue is to look at the donut hole in YOUR coverage.  The standard benefit plan is a minimum.  Insurance Companies can offer more benefits, with lower co pays.  See also our page on how to shop and compare.

Donut Hole Graphic

2019 Part D Graphic
2019 Part D Graphic

National Council on Aging Donut Hole Graphic

National Council Aging Donut Hole Graphic
National Council Aging Donut Hole Graphic

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.

Click here to enter your medications and comparison shop. all companies

*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 CA  Blue Cross  or  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

Our Website Introduction to Medicare  Prescription Drug Plans – Part D Rx  (credible coverage), Medicare.Gov on Part D Rx Coverage Gap

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.

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.

Child & Related Pages - Site Map 

Under 65 ACA preventative care

Steve’s explanation of the donut hole

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

Medicare and You 2019 - Everything you want to knowMedicare and You 2019 #10050 - Everything you want to know * See their section on closing the donut hole

2 comments on “Donut Hole – Coverage Gap

  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.

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