Medicare Part D’s “Donut Hole” Coverage Gap

What You Should Know About Medicare Part D’s

“Donut Hole” Coverage Gap

By Yvonne Tepsick

Most Medicare drug plans have a coverage gap known as a “donut hole”. This means there’s a limit on what the drug plan will cover for your drugs. Medicare Part D’s Coverage Gap” assists Medicare clients in handling the high cost of their medications.

Various insurance companies approved by Medicare offer affordable prescription drugs for the treatment of illnesses or permanent medical conditions. These plans will help you with the cost of your prescriptions as the price increases. If you’ve noticed that you are suddenly paying more for your drugs, you may be in the donut hole.

After you reach the “donut hole”, you will pay more of the drug costs from your own pocket. Brandname medication purchases are discounted by 75% (you pay 25%), but you will receive credit of 95% of the retail drug price towards meeting your total outof-pocket costs.

The Coverage Gap

The coverage gap may not affect everyone. In 2019 the Initial Coverage Limit of $3,820 marks the “Donut Hole” entry point.  Medicare beneficiaries enter the “Donut Hole” or Coverage Gap when the total negotiated retail value of their prescription drug purchases and co-payments exceed their plan’s initial coverage limit.

Healthier individuals may not spend that much money on prescription drugs while others may have “Extra Help”. If you qualify, Extra Help is a specialized federal program that helps people living on a limited income. Those individuals with Extra Help will not enter the coverage gap.

“Full” Extra help provides you with drug insurance coverage throughout the year and you will pay  less for prescriptions.  “Partial’ Extra Help offers coverage through the year, as well as a reduced deductible and premium.  Partial Extra Help has a 15% co-insurance or the plan co- pay, whichever is less.

How do I get out of the Donut Hole or Coverage Gap?

After spending $5,100 or more on outof-pocket expenses, that may include your yearly plan deductible, (which will go up $10 to $415 in 2019) and your monthly insurance co-payments and co-insurance, you are no longer part of the Coverage Gap and will automatically get Catastrophic Coverage. When Catastrophic Coverage is in effect, you will have a smaller amount to pay in prescription co-payments for the remaining months of the year.

Open Enrollment Has Started

If you want more information about the “donut hole” coverage gap or you’d like to change to a different Medicare Prescription plan, Open Enrollment is a good time. Open Enrollment starts on October 15 and runs through December 7.

Please make an appointment by calling me, Yvonne Tepsick at 352-350-6663. As an independent insurance agent, I’ll help you  examine your current coverage and find a good plan for your future health needs.


© 2017 – 2018, Charles Montgomery. All rights reserved.

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