.
.
.
. . .
. . .
Q1 Medicare.com  
Powered by Q1Group LLC Powered by Q1Group LLC.
Education and Decision Support Tools for the Medicare Community
.
.
. . .
. . .
. . .
.
. Home Contact Us MAPD PDP . .
. . 2016 FAQ Blog
.
. . .
. . . . . . .
.

When do I need coverage in the Donut Hole (or Coverage Gap)?

The Donut Hole or Coverage Gap is the portion of the Medicare Part D plan where, after a certain point, the Medicare beneficiary is 100% responsible for the costs of the medication.

In the 2015 Medicare Part D Plans, the coverage gap starts when the retail cost of the medications reaches $2960 and continues until the retail cost of the medication reaches $6680 (which is when you have spent $4700 in out of pocket costs for your medications). Please Note: The monthly retail cost of your medication may be available from your local pharmacist.

You can, therefore, calculate whether and when you go into the Coverage Gap by simply working with your estimated average monthly expenses.

For example, if you spend approximately $300 per month retail, you could expect to enter the Donut Hole in October: $2960 / $300 = 9.87 months into the calendar year or October.

You will therefore have 2.5 Months (12 months - 9.5 months ) during which you would be responsible for 100% of your medication costs - that is you will pay the full $300 per month yourself.


To determine if donut whole coverage is worth while, you need to take a look at the extra premium paid for the donut hole coverage as compared to the money saved in medication costs. (Please also note the many plans only cover generics in the donut hole!)

If the monthly premium costs of a Medicare Part D plan with Donut Hole coverage costs $30 more per month than a Medicare Part D plan without Donut Hole coverage (or an additional $360 more per year), and your monthly medications costs using the plan would be $100 co-pay per month instead of the $300 in retail costs, the calculation would be as follows.

You would be saving $200 a month on your medication costs ($300 - $100), for the 4 months that you would be in the Donut Hole for a total savings of $800 - which is in excess of the additional $360 premium cost for Donut Hole coverage. Therefore, in our example, the prescription drug cost savings will justify the additional monthly premiums.

Please note: in some cases, you will actually come out of the Donut Hole into the area of "Catastrophic Coverage". For example, if you have retail medication costs of $600 per month you go into the Donut Hole in May ($2960 / $600 = $4.93) and pay 100% of your medication costs until you come out of the Donut Hole in mid-November ($6680 / $600 = 11.13). The remainder of the year (from mid-November through December) you will fall under catastrophic coverage.
:: Top


Last updated on: 10/23/2013

Click the +1 button if you have found this page useful:  



.
.
.
Medicare Supplements
fill the gaps in your
Original Medicare
1. Select Your State:
.
.



.
Quick Links
: : Sign-up for our Medicare Part D Newsletter.
: : 2015 PDP-Finder: Medicare Part D (Drug Only) Plan Finder
: : PDP-Compare: 2014/2015 Medicare Part D plan changes
: : 2015 MA-Finder: Medicare Advantage Plan Finder
: : MA-Compare: 2014/2015 Medicare Advantage plan changes
: : Drug Finder: 2015 Medicare Part D plan drug search
: : Formulary Browse: View any 2015 Medicare plan formulary
: : 2015 Browse Drugs By Letter
: : PDP-Facts: 2015 Medicare Part D plan Facts & Figures
: : Medicare Part D Reminder Service: 2016
.

.

 
.
.
: : 2015 Medicare Part D Rx plans
: : 2015 Medicare Advantage plans
: : Browse any 2015 Drug Formulary
: : Find a Medicare plan by drug
: : Newsletter Sign-up
. . . .


.

:: Click here to link to this page on your website
.

    Follow Q1Medicare on Twitter
.

   
. .
. . .
. . .
.
.
What’s New Most Viewed Press . .
.
. . .
.
Sitemap About Us Privacy Policy Newsletter Sign-up Blog FAQ Contact Us Terms Of Use Newsroom
. Enroll in Medicare Part D © Q1Group LLC 2005 - 2015 . .
. . .
. . .
. .
. .

.
.

Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.


.
.
.