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Will you enter the 2017 Medicare Part D Donut Hole ... and if so, when?

Article 12 of 45 in this Category
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Will you enter the 2017 Medicare Part D Donut Hole ... and if so, when?
Published on 2017-01-02 14:30:34
Category: The Donut Hole or Coverage Gap

You will enter your Medicare Part D plan's Donut Hole or Coverage Gap if the total retail value of your formulary prescription purchases exceeds your plan's Initial Coverage Limit, and the 2017 standard Initial Coverage Limit is: $3,700.  This means that you will enter the 2017 Coverage Gap or Donut Hole if the retail cost of your medications averages over $309 each month.

Remember ... the retail drug cost of your medications is usually not what you actually spend for your prescriptions, but what is spent by you plus what your Medicare Part D plan pays (or others pay on your behalf).

For example, if you use a formulary medication that has a retail cost of $375 and you pay only a $60 co-pay with your Medicare Part D plan, your Medicare plan will pay the remaining $315, but the total retail cost of $375 counts toward meeting your Initial Coverage Limit or entering the Donut Hole.

The good news:  If your prescription costs have not changed since 2016 (which is unlikely), the 2017 Donut Hole or Coverage Gap should start just slightly later since the 2017 Initial Coverage Limit ($3,700) is slightly higher than the 2016 Initial Coverage Limit of $3,310.  In other words, you will be able to purchase more prescriptions before entering the 2017 Donut Hole as compared to 2016.  For example, if your average retail medication costs were $375 in 2016, you entered the 2016 Donut Hole in September 2016, however, if your costs remain the same this year, you will not enter the 2017 Donut Hole until sometime in October 2017.

And some more good news: No Donut Hole for Medicare beneficiaries with Extra Help
If you are qualified for the Medicare Part D Extra Help program or Low-Income Subsidy (LIS), then you will never enter the 2017 Donut Hole and the cost of your prescriptions will remain constant until you reach the Catastrophic Coverage portion of your Medicare Part D plan where your drug costs may actually be reduced depending on your income.  And if you are qualified for your state's Medicaid program, you are automatically qualified for Extra Help.

So if you are purchasing Medicare Part D drugs with a retail cost of over $309, when will you enter the 2017 Donut Hole?  The chart below shows the monthly retail drug costs that would cause you to enter the donut hole in any given month.

Minimum Average Monthly Retail Drug Cost
Causing You to Enter the Donut Hole in a Given Month

 You will enter
the Donut Hole in . . .
If your 2017
monthly retail drug
costs are over . . .
If your 2016
monthly retail drug
costs are over . . .
January $3,700 $3,310
February $1,850 $1,655
March $1,234 $1,104
April $925 $828
May $740 $662
June $617 $552
July $529 $473
August $463 $414
September $412 $368
October $370 $331
November $337 $301
December $309 $276

When you will enter the Donut Hole 2017 vs 2016 chart

Bottom line: If the retail cost of your medications averages over $309 each month, you will enter the Donut Hole some time in 2017.

Article 12 of 45 in this Category
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