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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 (18) 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...

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...

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...

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 ...

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...

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?
No and Yes.  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...

Newest FAQs in Category


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 ...

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...

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...

I purchased a Medicare Part D plan with coverage during the Doughnut Hole, so I guess I am protected throughout the year, right?
Maybe. In 2009 no Medicare Part D plan provides complete brand name and generic drug coverage through the Doughnut Hole. See the types of Gap Coverage available in 2009 as compared to 2008. Most Part ...

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...


Back To FAQ Home Browse All (18) FAQs in Category




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