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.
- Part D plans must cover at least the Part D standard benefit or its actuarial equivalent.
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2020 Part D Rx Donut Hole – Cost Sharing
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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.
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.
Email us if you have questions.
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.
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