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Questions & Answers (FAQ)

Browse the Medicare Part D "The Coverage Gap or Donut Hole or Doughnut Hole" FAQs
If you still have questions, please contact us through our Online Help Desk.

Category: The Coverage Gap or Donut Hole or Doughnut Hole

Back To FAQ Home Browse All (19) FAQs in Category

Most Viewed FAQs in Category


What exactly is TrOOP or True Out of Pocket costs?
The Centers for Medicare and Medicaid Services (CMS) explain that, "True out-of-pocket (TrOOP) costs are the expenses that count toward a person’s Medicare drug plan out-of-pocket threshold.&...

I read that my negotiated retail prescription drug costs go toward meeting my Initial Coverage Limit before reaching my Medicare Part D plan's Donut Hole, but is this the normal retail drug cost or the total cost in my Explanation of Benefits letter?
No. Your Medicare Part D plan's negotiated retail prescription drug cost can be (and usually is) different than the retail price that your pharmacy charges and that is reported in your Explanation of ...

What should I do now that I am in the Donut Hole or Coverage Gap? Is there any way to save money or are there programs available to help people like me pay for my prescription drugs?
Unfortunately, if you are in the coverage gap - and your Medicare Part D prescription drug plan does not provide any donut hole coverage (for instance, generic drug coverage), then there are only...

How do I know when I will reach my Medicare Part D plan's Donut Hole or Coverage Gap?
There are multiple ways to see how close you are to your Donut Hole.  Here are a few examples of how you can tell when you have reached your Medicare Part D plan's Doughnut Hole (or Coverage Gap)...

You say that I will enter my Medicare Part D plan's Doughnut Hole or Coverage Gap when my retail drug costs reach a certain dollar level that changes yearly. What exactly do you mean by "retail drug costs"? Is that what I spend on my pharmacy drugs?
The "retail costs" of medications that are used to calculate when you "fall" into the Coverage Gap or Doughnut Hole are the actual negotiated cost of formulary or Part D plan cover...

What costs do NOT count toward entering the Doughnut Hole?
Only the retail cost of prescription drugs purchased through and covered by your Medicare Part D plan (or Medicare Advantage plan that has a prescription benefit) are counted toward the entry into you...

When does a Medicare Part D beneficiary enter and exit the doughnut hole or coverage gap? The Doughnut Hole calculators seem to provide an estimate. But how does a beneficiary really know exactly when they enter and leave the coverage gap?
Leaving the Initial Coverage Phase and Entering into the Donut Hole A Medicare Part D beneficiary enters the  Doughnut Hole, Donut Hole  or Coverage Gap when their retail medication costs...

Can I avoid the Doughnut Hole if I buy a 90-day supply of my medications with the lower co-payment?
No.  Since your entry into the Doughnut Hole is based on your total retail drug expense, buying more medications at one time will actually accumulate your total retail drug cost faster and speed ...

If I enroll in a Medicare prescription drug plan that has an initial deductible, will it have any impact on when I go into, or out, of the Doughnut Hole or Coverage Gap?
Yes and No.  The Initial Deductible (you pay the first 100% of your prescription costs) does not affect when you go into the Donut Hole (Doughnut Hole) or Coverage Gap - but the Initial Deductibl...

I think that I have already spent my way through this year's Doughnut Hole. Is that possible?
Yes. If you use a great number of medications or one or more expensive medications, you can go through the Doughnut Hole rather quickly. A person enters the Coverage Gap portion of their Medicare Part...

Newest FAQs in Category


What exactly is TrOOP or True Out of Pocket costs?
The Centers for Medicare and Medicaid Services (CMS) explain that, "True out-of-pocket (TrOOP) costs are the expenses that count toward a person’s Medicare drug plan out-of-pocket threshold.&...

What costs do NOT count toward entering the Doughnut Hole?
Only the retail cost of prescription drugs purchased through and covered by your Medicare Part D plan (or Medicare Advantage plan that has a prescription benefit) are counted toward the entry into you...

Does the Donut Hole or Coverage Gap restart every year on January 1st or do we stay in the Coverage Gap from the previous year?
Yes, your Medicare Part D plan coverage, including your Donut Hole (or Doughnut Hole) or Coverage Gap begins again at the start of each new year. For example, if you were in the 2014 Coverage Gap, ...

I never knew that there was a gap in my prescription coverage. What is the Donut Hole?!
The Coverage Gap or Donut Hole is actually similar to a second deductible in an insurance policy where you are, once again responsible for your own coverage (or a portion of your own coverage due to...

I read that my negotiated retail prescription drug costs go toward meeting my Initial Coverage Limit before reaching my Medicare Part D plan's Donut Hole, but is this the normal retail drug cost or the total cost in my Explanation of Benefits letter?
No. Your Medicare Part D plan's negotiated retail prescription drug cost can be (and usually is) different than the retail price that your pharmacy charges and that is reported in your Explanation of ...

How do I know when I will reach my Medicare Part D plan's Donut Hole or Coverage Gap?
There are multiple ways to see how close you are to your Donut Hole.  Here are a few examples of how you can tell when you have reached your Medicare Part D plan's Doughnut Hole (or Coverage Gap)...

What should I do now that I am in the Donut Hole or Coverage Gap? Is there any way to save money or are there programs available to help people like me pay for my prescription drugs?
Unfortunately, if you are in the coverage gap - and your Medicare Part D prescription drug plan does not provide any donut hole coverage (for instance, generic drug coverage), then there are only...

If I have to pay 100% of my own drug costs when I go into the Doughnut Hole, why don’t I just stop paying my monthly Part D plan premiums?
We do not recommend that you stop paying your Medicare Part D premiums.  As we noted in our  July 2009 Newsletter, if you stop paying your Medicare Part D prescription drug plan premiums you...

Will you enter the Donut Hole or Coverage Gap this year?
You can determine when (or if) you will enter your Medicare Part D Donut Hole or Coverage Gap by just dividing your Medicare Part D prescription drug plan's Initial Coverage Limit by 12 months and ...

How exactly does the Coverage Gap fit into my prescription drug plan?
Your Medicare Part D plan can be divided into four possible parts or phases and you move through these parts of your prescription drug plan depending on your prescription drug spending. The Ini...


Back To FAQ Home Browse All (19) FAQs in Category




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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.
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  • 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.


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