You will receive a 75% discount on all formulary drugs if you reach the Donut Hole or Coverage Gap.
Changes coming to the Medicare Part D Donut Hole.Spoiler Alert
: In 2025, the the Inflation Reduction Act
will eliminate the Donut Hole or Coverage Gap and limit a Medicare Part D plan member's out-of-pocket costs for formulary drugs to $2,000 (the RxMOOP
, that can change every year after 2025). You can read more in the updates
below.A short history of the Donut Hole Discount.
As background, starting back in the 2011 Medicare Part D plan year, a discount or
co-insurance (cost-sharing) was introduced to reduce the cost of generic
and brand-name prescription drugs purchased by non-LIS Medicare
beneficiaries once they entered the Coverage Gap (or Donut Hole /
Doughnut Hole) portion of their stand-alone Medicare Part D prescription
drug plan (PDP
) (or Medicare Advantage plan that included prescription drug coverage (MAPD
: People who qualify for LIS (the Low-Income Subsidy or Extra Help
) do not have a Coverage Gap in their Part D plan,)
Over the years, the Donut Hole discount increased providing more coverage formulary drug purchases in Donut Hole.
Now if you reach the Donut Hole phase of your Medicare prescription drug plan and
your medication is on your plan's formulary and
you are not receiving financial Extra Help (LIS)
- You can take advantage of the 75% discount on all formulary drugs. (You pay 25% of your plan's negotiated retail cost for any formulary drug purchases made while in the Coverage Gap.)
Please see the charts below for Donut Hole discounts from 2011 up to 2020.
And as noted:
The Donut Hole discount is not available to anyone receiving financial Extra Help (the Low-Income Subsidy). Also, the Donut Hole discount is only for Medicare Part D drugs included on your Medicare prescription drug plan's formulary or drug list. If you buy a non-Part D drug
or purchase a non-formulary drug, you will not receive the Donut Hole discount.
Question: But I thought the Donut Hole closed?
Although we say that the Donut Hole "closed"
in 2020 -- because you receive a 75% discount on all formulary drugs
purchased in the Donut Hole (paying the same 25% cost-sharing as the standard Medicare Part D plan coverage before the Donut Hole) -- the Donut Hole did not go away and the
Coverage Gap remains the third phase of your Medicare Part D coverage.
So you still leave the second phase of your Medicare Part D plan or
Initial Coverage Phase once your retail drug costs exceed the Initial Coverage Limit
(ICL) And when you leave your Initial Coverage Phase, you will enter
the Coverage Gap (Donut Hole) where the cost of your formulary
medications can actually increase, decrease, or stay the same
- depending on your Medicare plan, your cost-sharing, and the drug's
retail price (see the examples below for more information).
The 75% Generic Drug Donut Hole Discount
The generic drug discount increased each year starting at 7% in 2011 until the plan year 2020 (and beyond) when you get a 75% discount, so the co-insurance for generics in the Coverage Gap is 25%
. The following table shows how the annual generic drug discount increased:
Generic Drug Discount
|2020 and beyond
You get credit toward exiting the Donut Hole for the portion of your drug costs that you actually paid -- the Beneficiary Cost-Sharing column in the chart above.
The 75% Brand-name Drug Discount
The brand-name drug discount began in 2011 at 50% and increased to 75% in 2019
(and beyond). Once again, you pay 25% for your drug purchases made while in the Donut Hole.
Brand-Name Drug Discount
|2020 and beyond
You get credit toward exiting the Donut Hole for the portion of your Donut Hole drug purchase that you paid, plus the portion paid by the brand-name drug manufacturer. So in 2019 and beyond, you get credit for 95% of the brand-name drug cost (25% paid by you and 70% paid by the brand-name drug manufacturer.
You can use https://PDP-Planner.com
to estimate your monthly costs based on your drug purchases.
** Update August, 2022:
Beginning in 2025, the 2022 Inflation Reduction Act
will provide Medicare Part D beneficiaries with a $2,000 maximum cap on out-of-pocket spending cap for Part D formulary drugs (RxMOOP
In 2025, the $2,000 RxMOOP should be reached when a person purchases
Medicare Part D formulary drugs with a retail value totaling $6,335.
The $2,000 RxMOOP can increase every year like other Medicare Part D
the addition of the $2,000 RxMOOP in 2025, Medicare Part D plans would have only
two parts of coverage (or less): (1) the Initial Deductible (if any)
and (2) the Initial Coverage Phase that would continue until December 31
of the plan year - or cease when the plan member's out-of-pocket
spending reached $2,000 and the person has no additional costs for Part D
Medicare Part D plans would no longer have the Part D
(Donut Hole with the accompanying Donut Hole discount
) and Catastrophic Coverage
** Update May, 2018:
In the document "American Patients First
The Trump Administration Blueprint to Lower Drug Prices and Reduce
Out-of-Pocket Costs (May 2018)", a proposal was made to exclude the
manufacturer's Donut Hole discount from the out-of-pocket (TrOOP)
calculation. If this proposal is implemented, research indicates
that fewer people will enter the Catastrophic Coverage phase and these
people will have higher out-of-pocket spending. (See also:
* Update February 12, 2018:
President Trump signed the Bipartisan Budget Act of 2018
on Friday, February 9, 2018 that effectively "closes" the Coverage Gap for
brand-name drugs, with the brand-name Donut
Hole discount increasing to 75% in 2019.
A key feature to the new law is that the
pharmaceutical industry will be responsible for 70% of the cost of
medications in the Coverage Gap, therefore you will receive credit
for 95% of the retail drug cost toward meeting your 2019 total
out-of-pocket maximum or Donut Hole exit point (the 25% of retail
the 70% drug manufacturer discount - see the next paragraph **
). As a note, since the brand-name drug manufacturer will take on an additional 20% of the retail cost, the Medicare Part D plan's responsibility will decrease to 5% (from the originally planned 20% in 2019 and 25% in 2020 and beyond), the Medicare beneficiaries portion will decrease to 25% (from the original planned 30% in 2019).
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