What does a donut hole mean in insurance?
Asked by: Melisa Cruickshank | Last update: December 20, 2023Score: 4.2/5 (21 votes)
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
Who pays for drugs in the donut hole?
You enter the donut hole when your total drug costs—including what you and your plan have paid for your drugs—reaches a certain limit. In 2023, that limit is $4,660. While in the coverage gap, you are responsible for a percentage of the cost of your drugs. How does the donut hole work?
How do you get out of donut hole?
Consider Extra Help or State Assistance Programs
If you qualify, the Extra Help program (also called the Low-Income Subsidy program) can provide financial assistance with Medicare Part D costs. You must have limited income and assets to qualify, and the specific qualification threshold may change each year.
What happens after you hit the donut hole?
Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit.
How long do you stay in the donut hole?
The amount of time you spend in the donut hole depends on the cost of your covered drugs and the benefits of the Part D plan you selected. Not everyone will get to the Medicare donut hole. If you do, you stay there until you've spent a specific amount for covered drugs. This amount changes each year.
Medicare Donut Hole Explained Simply
How do I find out if I am in the donut hole?
Once you and your Medicare Part D plan have spent a certain amount on covered prescription drugs during a calendar year ($4,660 in 2023), you reach the coverage gap and are considered in the “donut hole.” Not everyone will enter the “donut hole,” and people with Medicare who also have Extra Help will never enter it.
Does the donut hole end?
When did the donut hole close? The donut hole finally closed for good in 2020, having been phased out in 2019 for brand-name drugs and then in 2020 for generic drugs. The Affordable Care Act enacted in March 2010 gradually reduced the share of costs people had to pay in the donut hole starting in 2011.
How much do I have to pay in the donut hole?
Once in the gap, you'll pay no more than 25% of the cost for brand-name and generic prescription drugs covered by your Part D plan, although the full cost of those drugs will be used to move you closer to the Catastrophic Coverage stage.
How much do you spend before donut hole?
After you reach a total of $4,660, you enter the Coverage Gap stage, also known as the Donut Hole.
Does Medicare Advantage have a donut hole?
Some people ask: Do Medicare Advantage plans cover the donut hole? If you choose to include Medicare prescription drug coverage in your Medicare Advantage plan, it will still have a donut hole just like a regular Part D plan. Medicare Advantage does not cover any additional Part D costs during the coverage gap.
Can I use GoodRx if I'm in the donut hole?
GoodRx can't be used in combination with Medicare, but it can be used in place of Medicare. You may want to consider using GoodRx instead of Medicare when Medicare doesn't cover your medication, when you won't reach your annual deductible, or when you're in the coverage gap phase (“donut hole”) of your Medicare plan.
Can I avoid the donut hole?
If you have limited income and resources, you may want to see if you qualify to receive Medicare's Extra Help/Part D Low-Income Subsidy. People with Extra Help see significant savings on their drug plans and medications at the pharmacy, and do not fall into the donut hole. See if you qualify and apply today.
Does the donut hole reset each year?
Your Medicare Part D prescription drug plan coverage starts again each year — and along with your new coverage, your Donut Hole or Coverage Gap begins again each plan year. For example, your 2022 Donut Hole or Coverage Gap ends on December 31, 2022 (at midnight) along with your 2022 Medicare Part D plan coverage.
Is the donut hole good or bad?
If you have a Medicare Part D prescription drug plan, there's a gap in coverage after you've spent a certain amount on covered drugs. In this Medicare "donut hole," you stop paying your plan's usual copays or coinsurance. Instead, you pay up to 25% of the cost of your covered drugs, which could get pretty expensive.
How much is the donut hole for 2023?
What are the Medicare donut hole thresholds in 2023? In 2023, you'll enter the donut hole when your spending + your plan's spending reaches $4,660. And you leave the donut hole — and enter the catastrophic coverage level – when your spending + manufacturer discounts reach $7,400.
Do all prescription drug plans have a donut hole?
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
Is there a donut hole for Medicare Part B?
The donut hole won't affect all Medicare beneficiaries. If you have Original Medicare only (Parts A and B) and don't have a Medicare prescription drug plan (Part D or a Medicare Advantage plan that includes Part D), the donut hole won't affect you.
What will the Medicare donut hole be in 2024?
In 2024, costs in the catastrophic phase will change: the 5% coinsurance requirement for Part D enrollees will be eliminated and Part D plans will pay 20% of total drug costs in this phase instead of 15%.
What are the 4 phases of Part D coverage?
The Part D defined standard benefit has several phases, including a deductible, an initial coverage phase, a coverage gap phase, and catastrophic coverage, although it currently does not have a hard cap on out-of-pocket spending.
What is the deductible for Medicare Part D in 2023?
This is the amount you must pay each year for your prescriptions before your Medicare drug plan pays its share. Deductibles vary between Medicare drug plans. No Medicare drug plan may have a deductible more than $505 in 2023.
What is the deductible for Part D in 2023?
Most Part D PDP enrollees who remain in their current plan for 2023 will be in a plan with the standard (maximum) $505 deductible.
What is the Medicare coverage gap discount program?
The Medicare Coverage Gap Discount Program (Discount Program) makes manufacturer discounts available to eligible Medicare beneficiaries receiving applicable, covered Part D drugs, while in the coverage gap.
What is the out-of-pocket maximum for Medicare Part D?
Medicare Part D plans don't have hard out-of-pocket maximums. However, in all Part D plans, you enter what's called the catastrophic coverage phase after you hit $7,400 in out-of-pocket costs for covered drugs.
How much does eliquis cost per month?
This information is intended to help you understand the costs of ELIQUIS. The list price for a 30-day supply of ELIQUIS is $561. On average, patients pay $51 per month, and 5 out of 10 ELIQUIS patients pay $35 or less. Co-pay Card information.
What is the donut hole eating record?
Winner: Geoff Esper, with 293 Jack's Donut Holes in 8 mins. ESPER SETS DONUT HOLE WORLD RECORD! World! Major League Eating is proud to announce a new addition to our 2022 slate of sanctioned eating championships.