Whether you’re about to enroll in a Part D drug coverage plan or you’re already enrolled in one, it’s important to understand how the Medicare donut hole works.
Pour yourself a cup of coffee, and let’s dunk into the particulars.
Most Medicare drug plans have a coverage gap – also called the “donut hole.” This means there’s a temporary limit on what the drug plan will cover.
The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Once you and your plan have spent $4,130 on covered drugs in 2021, you’re in the donut hole. People with Medicare who qualify for Medicare’s Extra Help program won’t enter the coverage gap.
While you’re in the coverage gap, you’ll need to pay 25% of the cost of generic and brand-name drugs, until what you’ve paid in the year for covered drugs reaches $6,550. Catastrophic coverage kicks in once you’re out of the coverage gap, leaving you responsible for just 5% of your drug costs. This lasts until the end of the year when your coverage ends and your plan restarts.
To keep track of your current donut hole status, refer to your monthly Part D Explanation of Benefits (EOB).
How to avoid the donut hole
The main way to not hit the coverage gap is to keep your prescription drug cost low so you don’t reach the annual coverage gap threshold. Here are some ways to do that.
- Ask for generics when possible. Ask your doctor if any of your scripts can be switched to a less expensive generic option.
- Order your medications by mail. You may save when you order your medications in advance through a mail order pharmacy.
- Compare pharmacies. Since drug prices vary from pharmacy to pharmacy, it can pay to shop around.
You may qualify for the Extra Help program Medicare and Social Security have a program called Extra Help—a way for people with limited income and resources to get help with prescription costs. If you qualify for Extra Help, you could pay no more than:
- $3.70 for each generic covered drug
- $9.20 for each brand-name covered drug
To learn more, visit Medicare.gov/your-medicare-costs/get-help-paying-costs/lower-prescription-costs.
Or contact your local Blue Medicare Advantage Customer Service team at 866-508-7140 (TTY 711).