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If I receive Medicare Part D Extra Help, will I enter the Donut Hole?

Category: Entering the Donut Hole
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No.  If you qualify for the Medicare Part D Extra Help program or Low-Income Subsidy (LIS), then you will never enter the Donut Hole or Coverage Gap -- and the cost of your prescriptions will remain constant through most of your drug plan coverage.  In fact, your coverage cost for formulary drugs will only change if you reach the Catastrophic Coverage portion of your Medicare Part D plan.

And you will only reach the Catastrophic Coverage phase when your total out-of-pocket drug spending exceeds the annual threshold (for example, $7,050 in 2022 and projected to be $7,400 in 2023).  In Catastrophic Coverage, your drug costs will usually be greatly reduced.  (Costs in the Catastrophic Coverage phase can be as low as $0 or just slightly more based on your level of Extra Help).

Qualifying for Extra Help = No Donut Hole = No 75% Donut Hole discount

Since a person qualified for Extra Help never has a Coverage Gap in their Medicare Part D plan, they also will not receive the 75% Donut Hole discount, but instead will continue to pay low prices for your formulary brand and generic prescription drugs throughout the year.

PDPs meeting LIS $0 premium 2007 to 2021

For more details of Extra Help drug copayments during the first phases of coverage and after reaching the out-of-pocket threshold (entering Catastrophic Coverage), here are examples of full- and partial-Extra Help drug costs for: 2019, 2020, 2021 and 2022.

Important:  You can apply for Medicare Part D Extra Help at any time!

Remember, if you have limited income and financial resources, you can apply for the Medicare Part D Extra Help program (or Low-Income Subsidy) and receive help paying for your prescription drugs.

You can apply for Extra Help at any time of the year by visiting your local state Medicaid office, going to the Social Security website (www.socialsecurity.gov), or calling Social Security at 1-800-772-1213 (TTY users 1-800-325-0778).

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