2016 Medicare Part D Prescription Plan Donut Hole

Call First Medicare Advisors at: 1-800-825-2919
Email: [email protected]

This time of year we start receiving more and more phone calls from people who have reached the donut hole for Medicare Part D, and may need a refresher on what it is all about.

Entering the donut hole is not a function of time, but rather a function of expenses. In 2016, you will reach the donut hole – also known as coverage gap – when the amount of money you have spent, plus what the insurance carrier has spent on your behalf, reaches $3,310.00.

The donut hole is also referred to as the coverage gap, but that term is becoming less and less appropriate. Coverage gap, implies that you do not have coverage. That is not the case. Coverage inside the donut hole – or coverage gap – is increasing each year.

While you are in the first phase of coverage, you simply pay a co-pay for your prescriptions based on what tier the drug is in. Once you are in the donut hole, instead of paying a co-pay, you pay a discounted amount of the cost of the drug.

Last year you reached the donut hole at $2,850.00, this year at $3,310. You will get out of the donut hole when what you have spent out of your pocket totals $7,062.50.

Please note, getting into the donut hole looks at your expenses plus that of the insurance carriers. Getting out of the donut hole looks only at your expenses.

In 2016 you will get out of the donut hole at $7,063. Last year, when you were in the donut hole, you received a discount of 55% off your brand drugs, and 21% off your generic drugs.

This year the discounts are 45% off your brand, and 58% off your generic. As the discounts inside the donut hole get greater, your liability inside the donut hole shrinks. The donut hole is slated to close entirely, but not until 2020.

Our first suggestion to clients who are in the donut hole is do some comparison shopping. Your coverage in the donut hole is a discounted amount based on the original cost of the drug. You will now pay 45 % of the cost of a brand drug, and 58% of the cost of a generic. Prescription prices can vary.

I would suggest you call several pharmacies in your home town and inquire as to the price of some of your prescriptions. You may be surprised by what you hear! If you paying 45 % of the cost of a drug, it makes more sense to start with the lowest price possible.

The next suggestion we can offer is to speak with your doctor about the possibility of generics. Only you and your doctor can make decisions about what is best for you.

The final suggestion we can offer for those of you who have entered the donut hole already, is mark your calendar now for open enrollment. Open enrollment for Medicare Part D runs from October 15 through December 7.

This is the only time of the year you can change Part D plans. Perhaps another carrier or plan design would be more cost effective for you for 2017. You cannot change plans now, but may be able to find something more efficient for next year.

If you have questions about your Medicare Part D Prescription Plan or other related subjects, please feel free to call us at 1-800-825-2919. We will be happy to point you in the right direction. Remember we do not charge a fee for any of the services we provide.

Leave a Reply

Your email address will not be published. Required fields are marked *