What is the Donut Hole?

What is the Donut Hole?

Medicare has strict regulations around its prescription drug plans, and one of the most commonly asked about features is ‘the donut hole’. Also known as, ‘the coverage gap’, this benefit structure applies to both stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans, but not everyone enters it. If you’re currently taking medications or are concerned about lowering your prescription drug costs, it may be helpful for you to understand what the Medicare ‘Donut Hole’ is and how to avoid it.

2020 Prescription Benefit Chart

It may help you to understand the overall progress an individual may encounter as they fill their prescriptions throughout the year. This chart will serve as a useful aid. It describes the various stages that you may encounter. While a prescription plan is not required to have a deductible, if the plan does not, it is required to have an actuarial amount that is the same.

Coverage GAP

The coverage gap, commonly referred to ask “The Donut Hole” has several phases.
The coverage gap is a temporary limit on what most Part D Prescription Drug Plans or Medicare Advantage Prescription Drug plans pay for prescription drug costs. While you’re in the coverage gap, you might pay higher costs for brand-name and generic drugs. Below we’ve described each phase:

• Deductible period: For most stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans, you’ll pay 100% for medication costs until you reach the yearly deductible amount (if your plan has one). The standard deductible for 2021 is $445.
• Initial coverage period: After you’ve reached the deductible, you’ll enter the initial coverage phase, where you will pay the plan’s cost share for covered medications. For example, if your plan benefit includes a 25% coinsurance in this phase and you’re taking a medication that costs $400 a month, your out-of-pocket-cost would be approximately $100 a month.
• Coverage gap, also known as the “donut hole”: begins if you and your plan spend a combined $4,130 in 2021 as described above. While in the coverage gap, you’ll typically pay 25% of the plan’s cost for brand-name drugs and 25% of the plan’s cost for generic drugs in 2021. You’re out of the coverage gap once your yearly out-of-pocket drug costs reach $6,550 in 2021.
• Catastrophic coverage period: Begins if your out-of-pocket costs reach 2021 will be $6,550. During the catastrophic coverage phase, you’ll only pay a small coinsurance or copayment for covered prescription drugs for the remainder of the year. In the year 2021, a beneficiary will pay either a copay of $3.70 for generic drugs or $9.20 for name-brand drugs, or a coinsurance of 5%, whichever is greater.

Closing the Gap

Legislation has been signed to diminish the size of the coverage gap.

Below is a chart of how the costs are diminishing each year within the coverage gap.