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What is a Medicare Donut Hole, and how does it Work?

Medicare coverage gap

The majority of Medicare Part D prescription drug programs have a coverage gap. This is commonly known as the “donut hole.”

The term “donut hole” refers to the point at which a drug plan’s coverage for medications reaches its limit. When you and your Medicare Part D plan spend a certain amount on covered prescriptions in a calendar year (around $4,130 in 2021), you have reached the coverage gap and are considered to be in the “donut hole.”

Not everyone will fall into the “donut hole,” and people with Medicare who receive Extra Help will never enter it. 

How does the Medicare Donut Hole Works

There are four stages of Medicare prescription coverage. It begins with your deductible and ends with a catastrophic coverage plan. Regular coverage begins after meeting your deductible and continues until you reach your out-of-pocket maximum of $4,130. It is where things get complicated.

There is a gap of $2,420 between the time you reach your out-of-pocket maximum and the time your catastrophic coverage kicks in at $6,550.

Technically, since you have met your out-of-pocket limit, you should not be required to make any additional payments. However, because catastrophic coverage does not kick in for a further $2,420, you’re left wondering, “Now what?”

Stages of Coverages

i) Deductible — the amount varies by program

ii) Initial coverage — you pay copayments and coinsurance

iii) Coverage gap (Donut hole) — begin when you reach the Medicare out-of-pocket maximum ($4,130 in 2021).

iv) Catastrophic coverage — begin when you reach Medicare’s maximum out-of-pocket limit ($6,550 in 2021). 

So, how do these tiers interact with one another, and how do you avoid a potential donut hole? The first step in understanding what counts toward the Medicare “donut hole” is to learn about your plan’s coverage.

How much is My Deductible?

The deductible is the maximum amount of out-of-pocket costs you must pay before your insurance plan covers benefits. This amount varies depending on the program you select. 

Some coverages may not have any insurance deductible. Typically, no-deductible programs have higher monthly premiums.

What is meant by Initial Coverage Period?

You will pay the stated coinsurance or copayment fees for generic or brand-name medications during the first year of coverage. Your specific plan details determine the exact amounts of these costs and vary based on your plan coverage.

Many Medicare enrollees will remain in this stage for the entire program year; it all depends on the prices of your prescriptions and the medications you use.

What exactly is the Coverage Gap?

As previously stated, the coverage gap is the Medicare term commonly used to describe the donut hole. Each year, Medicare establishes a limit for out-of-pocket expenses that you can incur before reaching the donut hole.

In 2021, you enter the Medicare donut hole when you and your plan’s out-of-pocket spending reach a drug cost of $4,130, but catastrophic coverage does not enter until your out-of-pocket costs approach $6,550. As a result, the gap occurs.

Some plans do provide additional discounts during this period, and in many circumstances, you will only pay 25% of the total drug cost. However, you must remain vigilant because if you are taking multiple medications or your prescriptions are very expensive, it is worth considering what alternatives are available.

The best thing you can do is contact Medicare directly or speak with a licensed insurance professional to get personalized advice on your next steps if you fall into the coverage gap.

What is the Catastrophic Coverage Stage?

If your out-of-pocket expenses are around $6,550 for the year, you enter the catastrophic coverage phase. After that, you only pay a low coinsurance or copayment for covered prescription drugs for the rest of the year. 

What Counts Toward the “Medicare Donut Hole”?

Not every out-of-pocket expense will count toward reaching the donut hole — or even counts toward the amount required to exit the donut hole and enter the catastrophic coverage stage. That’s why it is critical to understand what applies and what does not.

What are the Medicare Donut Hole Rules for 2022?

Previously, being in the donut hole indicated you need to pay out-of-pocket costs until you reached the threshold value for more drug coverage. Nevertheless, the donut hole has been closing due to the introduction of the Affordable Care Act.

Several changes are planned for 2022 to reduce your out-of-pocket costs during the coverage gap. It includes:

  • You will spend no more than 25% of the cost of brand-name medications.
  • The nearly total price of the medicine (more than what you have paid out-of-pocket, or 95% of its costs) will count toward closing the coverage gap.
  • You must pay a dispensing fee for your medication. Your plan will cover 75% of the cost, while you will cover the remaining 25%.
  • Fees that do not count toward your OOP funding include 5 percent that your coverage pays and 75 percent that your plan spends toward the dispensing fee.

Some programs even offer significant discounts when you’re in the coverage gap phase. It’s critical to carefully read your plan to see if this applies to you.

Let’s look at the examples to see how this works.

Generic drugs

The only amount you pay for generic drugs counts toward your OOP threshold. For example:

  • You’re currently in the donut hole, where a covered generic medicine costs nearly $40, and the dispensing fee equals $2.
  • You need to pay 25 percent of this cost out of pocket (OOP), which is $10. Also, you are responsible for paying the dispensing fee of $0.50.
  • Only this $10.50 will be deducted from your out-of-pocket expenses for leaving the donut hole. The remaining $30 will not be counted.

Brand-name Drugs

In the case of brand-name medications, 95 percent of the total medication cost will be counted toward reaching the OOP limit. This includes the 25% OOP fee as well as a manufacturer discount. 

As an example, consider the following:

  • You’re in the Medicare donut hole, and a covered branded drug costs $40. The dispensing fee is around $4.
  • You will pay 25% of this price OOP, which is $10. Moreover, you will also be charged 25% of the dispensing fee, or $1.
  • The manufacturer’s rebate will be 70%, or $28. Your coverage will cover the remaining 5%, or $2. Also, they pay 75% of the dispensing fee, or $3.
  • This comes to a total of $39. This amount will count to your out-of-pocket expenses for getting out of the Medicare donut hole. The remaining $5 will not be included.

What Happens when I Exit the Medicare Donut Hole?

After you get out of the donut hole, you will be eligible for catastrophic coverage. This means you’ll be required to pay whatever is higher for the rest of the year: 5% of the prescription’s cost or a small copay.

The minimum copay for 2022 has increased over the years from 2021:

  • Generic drugs: the minimum copay is $3.95, slightly higher compared to $3.70 in 2021.
  • Brand-name drugs have a minimum copay of $9.85, up from $9.20 in 2021.

Understanding Medicare Part D

Medicare Part D is an optional Medicare plan that provides prescription drug coverage. Medicare-approved insurance providers offer this coverage.

Before starting Part D, many people obtained prescription drug coverage through their company or a private plan. The projected average monthly premium for those who purchase a basic Part D plan in 2022 is $33. This average is slightly higher than the average monthly premium in 2021, which is $31.47.

Medicare Part D plans provide coverage for both brand-name and generic drugs. The formulary is a list of drugs that includes at least two drugs from commonly prescribed drug categories.

However, the drugs covered by your Part D plan may change from year to year. Your supplier can make adjustments to its formulary at any time of year as long as it follows the specific guidelines. This can include things like switching from brand-name to generic medications.

Six Strategies to Reduce Overall Medicare Prescription Drug Costs

Is there anything else that you can do to minimize the cost of prescription medications? Below are six recommendations:

1) Think about switching to generic medications

These are typically less expensive than brand-name medications. If you’re turning to a brand-name medication, talk to your doctor about generic alternatives. 

2) Consider ordering medications online

This might be more cost-effective in some cases. The FDA has compiled a list of tips for safely purchasing medications online.

3) Select a plan that provides additional coverage during the “donut hole”

Some health insurance programs may provide extra coverage while you are in the Medicare donut hole. However, you might be subject to considerable premiums.

4) Find state-sponsored pharmaceutical assistance programs

Many states have programs that can help you pay for your prescriptions. Medicare has a search tool that can help you find programs in your state.

5) Search for pharmaceutical assistance policies

Many pharmaceutical companies provide assistance programs to people who require assistance with the cost of their medication.

6) Submit your application for Medicare Extra Help

People with Medicare drug coverage, low income, and few resources may be eligible for the Medicare Extra Help program. This contributes to the expenses of deductibles, copayments, and premiums associated with the Medicare plan. 

Key Takeaways

  • The Medicare “donut hole” refers to the coverage gap in Plan D prescription coverage. You will enter it after you have reached an initial coverage limit.
  • In 2022, you will be required to pay 25% out-of-pocket from the time you fall into the donut hole until you meet the out-of-pocket threshold.
  • There are different alternatives you can do to help reduce the cost of medications. These include turning to generic drugs, having additional coverage for the donut hole, and using the assistance program.
  • When choosing a Medicare drug plan, make sure the plan covers your prescriptions. It’s always a good idea to compare different programs and find the best Medicare plan for you.