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 the result will tell you the retail
value of prescription drugs you need to purchase per month before entering
the Donut Hole at some time during that year.
For example, in 2024, the
standard Initial Coverage Limit
is $5,030, and you would enter into the 2023 Coverage Gap or Donut Hole if
you purchase prescription drugs with a retail value of over
$420 per month.
However, in 2013, the
standard Initial Coverage Limit was $2,970, so if your prescription drug purchases
had a retail value of over
$247.50 per month, you would have
entered into the 2013 Coverage Gap or Donut Hole.
As an older example, you would have entered the 2009 Donut Hole when your
total retail prescription costs exceeded the 2009 Initial Coverage Limit
of $2,700 in one year. This means that if your 2009 monthly retail
prescription drug costs were over
$225 per month, you
would go into the Donut Hole some time before the end of 2009.
Here is a short list of popular brand-name medications from 2009 and their
approximate retail price to give you an idea of how easy it was for the
total cost of your prescriptions to reach a retail value of over
$225 per month (the actual 2009 negotiated retail price
for each drug would vary slightly with your Medicare Part D plan):
Brand
Names® |
Form / Strength |
2009
Retail Cost
|
2020
Retail Cost
|
Actonel® |
Tab 35 MG |
$89 |
$344 |
Advair Diskus® |
MIS 250/50 |
$200 |
$416 |
Ambien® |
Tab 10 MG |
$154 |
$606 |
Diovan® |
Tab 80 MG |
$68 |
$235 |
Lipitor® |
Tab 10 MG |
$85 |
$317 |
Lotrel® |
Cap 5-20 MG |
$97 |
$300 |
Nexium® |
Cap 40 MG |
$162 |
$302 |
Norvasc® |
Tab 10 MG |
$80 |
$271 |
Plavix® |
Tab 75 MG |
$145 |
$205 |
Prevacid® |
Cap 30 MG DR |
$158 |
$439 |
Zocor® |
Tab 20 MG |
$147 |
$256 |
Zoloft® |
Tab 100 MG |
$101 |
$337 |
In 2009, if you had average monthly retail drug costs of $338 for formulary drugs,
you would have entered the Donut Hole in August, see:
PDP-Planner.com/2009.
In 2020 your retail drug cost for formulary drugs would have to be over
$503
per month for you to enter the Donut Hole in August. See
PDP-Planner.com/2020.
In 2023, your average monthly retail drug costs of $583 for formulary drugs,
you would have entered the Donut Hole in August. See:
PDP-Planner.com/2023.
In 2024, your average monthly retail drug costs of $629 for formulary drugs,
you would have entered the Donut Hole in August. See:
PDP-Planner.com/2024.
Important
Fact: 2024 is the last year that the Donut Hole will exist.
In 2025 one of the provisions
of the
Inflation Reduction Act (IRA) of 2022 is the elimination of
the Coverage Gap (Donut Hole). Medicare Part D beneficiaries will stay
in the
Initial Coverage phase until they reach the maximum cap on
out-of-pocket spending for Part D formulary drugs -
RxMOOP - which is set at $2,000 for 2025. After
reaching RxMOOP Medicare Part D beneficiaries will have a $0 copay for all
formulary drugs.
Do you still have questions about how the Coverage Gap or Doughnut Hole works with your
Medicare prescription drug plan?
No problem, just click here and we will try to answer your question.