Medicare Donut-Hole 2015 at a Glance

by Ray Wilson+ on Feb 04, 2015 | 6 Comments

The majority of Medicare prescription drug plans (PDP) will reach a coverage gap, known as the donut-hole, which limits what the insurer will cover for your drugs. Let us explain your 2015 drug costs are during the donut hole.

Donut-Hole 2015

In 2015, if your Medicare Part D drug plan has a coverage gap once you and your insurance provider have paid $2,960 toward your covered drugs and you exit it at $4,700. Here is what you’ll owe for generics and your plan’s covered brand name drugs during the donut-hole:

  • Generic costs: 65%
  • Brand name costs: 45%

Brand Name Rx During Donut-Hole

Even though you only pay 45% of the cost of your insurance provider’s approved brand name drugs during the donut-hole, both what you pay AND what the 50% manufacture’s discount helps to get you out of the donut-hole (minus dispensing costs and drug costs). Here are the three steps to figure out what your total out of pocket spending equals:

    1) If you are prescribed a drug that costs $100 and a $5 dispensing fee, you would pay (100 x .45) $45 for the drug and (5 x .45) $2.25 for the dispensing fee for a total of $47.25, THEN
    2) The manufacture’s discount would total (100 x .5) $50, SO
    3) Your total counted toward out of pocket spending would be $97.25

Generics During Donut-Hole

Generic drugs total out of pocket spending is broken down differently from brand-name drugs. It is ONLY the amount you pay toward your generic drugs that helps you out of the donut hole; a manufacturer’s discount doesn’t apply.

Not All Plans Enter Donut-Hole

While most plans will enter the PDP donut-hole, there are some plans that do not. These plans are called enhanced. While an enhanced plan can offer coverage gap coverage, just by purchasing an enhanced plan does not guarantee it will cover you during the gap, and if it does it does not mean that it will cover all of your drugs. Make sure to do your research. Click here to see the difference between basic and enhanced drug plans.

Next Steps
During Medicare’s open enrollment (Oct 15 -Dec 7) you can switch or enroll, BUT you may still be able to change your current plan outside of open enrollment if you switch to a 5-star rated prescription drug plan. For further questions about drug plan coverage gaps call the number above or contact Senior65.

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Reader Comments and Questions

By Joan Segal on September 18, 2016

what happens if you go over the threshold of entering the donut hole by a few extra dollars....will the entire order you placed with pharmacy at that time be subject to prices/costs of the donut hole....or is some calculation made of just the amount you go over. this sounds more complicated than it is; i just don't know the answer. thank you

Joan,
Once you hit the Part D donut hole, all prescriptions you take will be subject to the donut hole. Remember the most important thing you should do each year is to see how each Part D plan covers your drugs. We can help you determine if you will hit the donut hole, and what each drug will cost before, during, and after the donut hole threshold. For help with this, call one of our Senior65 licensed independent insurance agents at 800-930-7956.
-Amy from https://www.senior65.com/


By William Dunlop on June 29, 2016

My question is are all the donut holes the same amount and is the castrope the same amount with all insurance companies for Medicare D. I appreciate your comment. William Dunlop

William,
Most Part D prescription drug plans will enter the donut hole. And, there is a set amount for the donut hole. With that said, it is important to learn how each plan covers your current drugs to learn how soon you would hit the donut hole or if you would hit the donut hole at all. If you need help comparing drug plans in your area, call one of our Senior65 licensed independent insurance agents at 800-930-7956.
-Chris from https://www.senior65.com/


By linda brown on October 18, 2015

I have Medicare A and B and United Health care as a supplemental. Somehow I do not have any rx coverage. I am 68 years old. Do I have to call Medicare (do I have 'D'?) Or can I just call/enroll in Silver Scripts, or do I have to have United's rx coverage? I don't want to risk not having prescription coverage again next year.

Linda,
Good news, bad news here. Good news: You can enroll directly into any Part D plan that is available in your area. Bad news: You'll owe a 1% penalty for each month you were eligible to enroll in a prescription drug, but didn't. Please contact us at 800-930-7956, if you would like help enrolling in a prescription drug plan.
-Jacima from https://www.senior65.com/


By robert maxwell on August 12, 2015

moving to Denmark…in order for this veteran can survive this wonderful country,my wife's "Obamacare" tax subsidy is $130/mo.I live on social security and my wife works at Walmart part time so we pay 400/mo. for insurance that does not cover anything until the $6000 deductible is paid first(total annual cost of$10800 until one cent paid by the the insurance companies…….freedom is having nothing left to lose,and it makes us very dangerous…...


By Harold on June 23, 2015

What's the best way to pick a drug plan? I take 8 prescription drugs a day and I'm turning 65 in July.

Harold,
The best way to pick a Medicare drug plan is to get a list of your current drugs and dosages then call us at 800-930-7956 and we'll plug them in to find the plan that will offer the most coverage in your area.
-Jacima from https://www.senior65.com/


By sean k. on April 30, 2015

If I spend more money each month on my plan, will I have better coverage?

Sean,
Thank you for your question. Don't we all wish it were that simple! But the truth is your actual cost is based on your current drugs. If you'd like to learn which is your best drug plan you can call us with a list of your drugs and we'll let you know which is the least expensive plan in your area (800-930-7956).
-Amy from https://www.senior65.com/










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