Medicare prescription drug plans come with a unique feature known as the “donut hole”. This phase of coverage can be a source of confusion and concern for many, but understanding how it works and how to make the most of your coverage options can help save you money and maintain your health.
In this blog post, we will explore what the donut hole is, how it affects your prescription drug costs, and recommend an alternative that will help you maximize your coverage and minimize your out-of-pocket costs during this phase.
What is the Donut Hole?
The donut hole is a phase of Medicare prescription drug coverage where your cost-sharing may temporarily change based on the type of drugs you’re taking. You may have to pay more for your prescription drugs when you reach this phase. This coverage gap is something to be aware of as it can significantly impact your budget. Note that those who receive “Extra Help”* never enter the coverage gap.
Here’s How the “Donut Hole” Works:
- Entering the Donut Hole: Once you and your drug plan have spent $4,660 (2023) or $5,030 (2024), you enter the coverage gap, or “donut hole” phase, of your Medicare prescription drug coverage.
- Cost-Sharing in the Donut Hole: During this phase, you may pay 25% of the total cost of brand- name and generic drugs or your plan’s cost share if it has extra coverage through the coverage gap. Be sure to check your plan’s Evidence of Coverage (EOC) to understand your specific costs.
- Exiting the Donut Hole: When you’re cost-sharing, nearly the entire cost of the drug counts as out-of-pocket spending. You will leave the coverage gap when your out-of-pocket drug costs reach $7,400.
Understanding the donut hole phase and how it affects your prescription drug coverage is crucial for managing your healthcare costs effectively. If you have a chronic condition, the high cost of medications could land you in the donut hole in just a couple of months. Your out-of-pocket costs will be significant until you reach the $7,400 exit point for prescription drug coverage where catastrophic prescription drug coverage kicks in1. You can also find out more about coverage in the gap on medicare.gov.
Gold Kidney Has You Covered
Gold Kidney Medicare Advantage plans have you covered in the coverage gap with copays as low as $0 per prescription, covering many name-brand drugs** including Farxiga®, Jardiance®, Ozempic®, Trajenta®, Trulicity®, Victoza® 3-pak, and many more.
We help you navigate the “donut hole” with confidence to make the most of your Medicare Advantage plan benefits including additional prescription drug benefits when you need them most.
Please reach out to a Gold Kidney Health Plan representative for more information and personalized guidance to ensure you have the benefits you need to live your best life.
Call us at 844-294-6535 (TTY: 711) or complete the form below.
We will be happy to assist you.
*Extra Help is a Medicare program to provide extra assistance to those with limited income and resources to pay Medicare Part D coverage.
**Benefits vary by plan
1 https://www.medicalnewstoday.com/articles/does-medicare-cover-prescription-drugs#:~:text=In%20the%20coverage%20gap%2C%20a%20person%20pays%2025%25,limit%2C%20their%20catast rophic%20prescription%20drug%20coverage%20kicks%20in.