The
2015 Donut Hole discount will increase to 55% for all brand-name medications purchased in the Donut Hole (you pay 45% of the retail cost and get 95% credit toward TrOOP) and the 2015 generic Donut Hole discount will increase to 35% (you pay 65% of the retail cost).
Popular Question: So who is paying the Donut Hole discount and does the discount count toward getting out of the Coverage Gap?
The generic drug Donut Hole discount is paid by your Medicare Part D plan and does not count toward TrOOP (getting out of the Donut Hole).
The brand-name drug discount is split into two parts (beginning in 2013). The first portion, is a 50% discount paid by the drug manufacturer as it has been since 2011. The additional 5% discount in 2015 is considered plan coverage and is paid by your 2015 Medicare Part D prescription drug plan.
Since both the generic discount and this additional 5% brand-name drug discount are paid by your plan and considered plan coverage, they do not count toward getting out of the Donut Hole or meeting your True Out-of-Pocket costs (TrOOP).
Therefore, 50% of the brand-name discount – that portion paid by the manufacturer, will continue to count toward your TrOOP along with the 45% of the retail price that you will pay.
Here is an example of how this works: In 2015, if you buy a brand-name drug that has a retail price of $100, you will pay $45 (a 55% discount). For this Donut Hole purchase, $95 will count toward getting out of the 2015 Donut Hole (or meeting your
2015 TrOOP limit of $4,700 ) – the $45 you paid
plus the $50 brand-name drug discount paid by the drug manufacturer.
The extra $5 portion of the discount will not count toward TrOOP because it was paid by your Medicare Part D plan and is considered plan coverage.
However, if you purchased a $100 generic medication while in the 2015 Donut Hole, you would pay $65 (receiving a 35% discount) and only the $65 you paid would count toward your 2015 TrOOP or Donut Hole exit point.