About $3,019 - maybe even a little more depending on your Medicare Part D plan
However, your actual savings in the
2019 Donut Hole
will depend on several things including:
(1) How much you spent personally (out-of-pocket) on your formulary drugs before reaching the Donut Hole portion of your Medicare Part D prescription drug coverage.
(2) How much you spend on generic drugs vs. brand-name medications while in the
2019 Donut Hole (reminder: while you are in the 2019 Donut Hole,
you will receive a 63% discount on generic drugs
and receive a 75% discount on name-brand
). Keep in mind that you get credit for 95% of the brand-name drug purchase
costs toward meeting your 2019 out-of-pocket threshold limit (or TrOOP) of $5,100.
The 95% includes the 70% discount paid by the brand-name drug manufacturer and the 25% paid
by you. The 5% discount paid by your Medicare Part D plan does not count toward TrOOP.
Here is an example showing how to estimate your savings with the Donut Hole discount. To make the example simpler, we are assuming:
(1) Your Medicare Part D prescription drug plan has the standard $415 Initial Deductible
(many people are enrolled in a Part D plan with a $0 deductible).
(2) Your plan has a standard 25% co-insurance cost-sharing structure
(this means that you pay 25% of the retail cost of a medication and the plan pays the other 75%). In reality, your Medicare Part D drug plan may have a fixed co-pay amount for all the drug tiers (such as Tier 1 drug co-pays are $8),
instead of cost-sharing that is a percentage of your drug's retail cost.
(3) You purchase only brand-name medications while in the Donut Hole.
(4) You spend your way through your entire Coverage Gap or Donut Hole
by meeting the $5,100 out-of-pocket threshold or TrOOP
Based on these assumptions, the amount that you could save with the 2019 Donut Hole discount would be about $3,019.08
(or 75% of $4,025.44).
And here is our math along with a few more assumptions:
- Your 2019 Medicare Part D Initial Deductible: $415.
- The standard 2019 Initial Coverage Limit: $3,820 (or the total retail drug cost).
- You have a 25% cost-sharing - so, of the $3,820, you pay $851.25 during the Initial Coverage phase (.25 x ( $3,820 - $415)) .
- The remaining balance you need to reach the 2019 Donut Hole exit point or TrOOP threshold of $5,100 is $3,833.75 ($5,100 (TrOOP) - $851.25 (after deductible cost) - $415 (deductible cost).
- If you purchase $3,833.75 in brand-name drugs while in the
Donut Hole you get the 75% Donut Hole discount on your purchases, so
you pay $958.44 (.25 x $3,833.75) -- and you only get credit
for $3,642.06 toward meeting the $5,100 TrOOP threshold or Donut Hole
exit point (not the full $3,833.75, but 95% of the retail cost).
- Therefore, since you only get credit for 95% of your brand-name prescription purchases while in the Donut Hole,
you calculate your new Donut Hole exit point by dividing the coverage gap spending amount
($3,833.75) by .95 for a total of $3,642.06. Or you can look at it as
-- you actually have to buy $191.69 more in medications to meet your TrOOP threshold and this extra amount accounts for the discount paid by your plan (because you do not get
credit toward TrOOP for the amount paid by your plan).
- We would estimate your Donut Hole savings as then $3,019.08 or
($3,833.75 + $191.69 = $4,025.44) x 75%.
- If you had a Medicare Part D $0 Initial Deductible,
your savings would be $3,264.19 or $245.11 more in savings as compared to a Medicare Part D plan
with the standard $415 Initial Deductible.
If you select a 2019 Medicare Part D plan that has an average
cost-sharing structure of lower than 25% (you pay less than $25 for a $100 drug purchase),
you will save even more money with the 2019 Donut Hole discount when you reach the
Donut Hole or Coverage Gap, because you will have more of your total out-of-pocket costs
falling into the 2019 Donut Hole where you get the 75% name-brand Donut Hole discount.
For more information, you can click here to see how the Donut Hole discount has increased
over the years until 2020 when the discount reaches 75% for all formulary medication -- and the Donut Hole is considered “closed”.
See our FAQ #530 for examples of the maximum Donut Hole Discount savings for other plan years
or see our Blog for more about Donut Hole discounts
Our 2019 PDP-Planner
(or Donut Hole Calculator) is available to illustrate your monthly estimated costs for 2019.
Several examples are available to help you get started. Click here for an example
of a Medicare beneficiary with relatively high monthly prescription drug costs (a retail drug cost of $800 per month). Spoiler Alert: Even though your retail drug costs in this $800/month example are $9,600 per year, you would pay about $2,362 out-of-pocket (not counting your monthly premiums) when using your Medicare Part D plan.
You can also click on the following link to learn more about the 2019 Medicare Part D drug coverage