Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community

FAQs on Closing the Coverage Gap



Browse the Most Viewed and Newest Medicare Part D FAQs
If you still have questions, please contact us through our Online Help Desk.

Category: Closing the Coverage Gap


Most Viewed FAQs in Category
What kind of discount can we expect in the Medicare Part D Donut Hole or Coverage Gap?
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 . . .

What exactly is TrOOP or Total Out-of-Pocket costs?
The Centers for Medicare and Medicaid Services (CMS) explains that, "[Total or] True out-of-pocket (TrOOP) costs are the expenses that count toward a person’s Medicare drug plan out-of-pocket . . .

How much do I have to pay for generics in the donut hole in 2011, 2012, 2013,2014, 2015, etc. until it reaches 25%
Even if your Medicare Part D plan has no coverage in the gap, starting in 2011, you receive a discount on your medications while in the coverage gap. For generic drugs, you would pay the following p . . .

Will the Coverage Gap or Donut Hole eventually just close and go away?
Not exactly.  The Donut Hole will not be eliminated from your Medicare Part D prescription drug plan coverage.  Sometimes members of the press, government, or advocates infer that the Donut . . .

For 2011 you indicate that the full retail cost of drugs while in the donut hole will apply to the amount required to get out for name brands even though I'm only paying 50%. Can you clarify?
Complete Question: For 2011 you indicate that the full retail cost of drugs while in the donut hole will apply to the amount required to get out for name brands even though I'm only paying 50%. I talk . . .

I asked my pharmacist about the new discount program and he did not seem to know anything about it. So will I still receive this 50% discount on my refills while I am in the doughnut hole or do I need to find another pharmacy?
Complete Question: I use one expensive medication that cost almost $2000 a month and I have already reached my Doughnut Hole for this year. I asked my pharmacist about the new discount program and he . . .

My current prescription drug retail cost are $230 per month. What will be my discount in the Doughnut Hole?
If your total retail prescription medication costs are under $236, you will not exceed your plan's Initial Coverage Limit ($2,840 per year for 2011) and so you will not need to take adv . . .

Will all generic drugs get the Coverage Gap discount or only generics drugs in Tier 1 or the lowest formulary tier?
All generics covered on your Medicare Part D plan's Formulary will receive the Doughnut discount.  The discount on generic drugs purchased in the Coverage Gap applies to all generics covered as f . . .

If I go into the Coverage Gap, will my Donut Hole discount be deducted at the pharmacy or will I get a refund from my Part D plan?
You will receive the discount directly at the Pharmacy. The Donut Hole discount on medications purchased in the Coverage Gap will be calculated at the point-of-sale (or Pharmacy). However, calculatin . . .

Will the Coverage Gap discount program affect which brand-name drugs are offered under Medicare Part D?
It is possible. The Affordable Care Act limits Medicare Part D coverage for applicable drugs to only those drug manufacturers that have an agreement with CMS to participate and pay discounts under the . . .

Newest FAQs in Category
Will I receive the Donut Hole discount for the portion of my compounded prescription that is covered by my Medicare Part D plan?
No.  Medicare changed positions on this policy and first provided Donut Hole discounts for compounded Medicare Part D drugs in May 2010: "Part D sponsors shall only provide a discount on a com . . .

Will the Coverage Gap or Donut Hole eventually just close and go away?
Not exactly.  The Donut Hole will not be eliminated from your Medicare Part D prescription drug plan coverage.  Sometimes members of the press, government, or advocates infer that the Donut . . .

What exactly is TrOOP or Total Out-of-Pocket costs?
The Centers for Medicare and Medicaid Services (CMS) explains that, "[Total or] True out-of-pocket (TrOOP) costs are the expenses that count toward a person’s Medicare drug plan out-of-pocket . . .

I use a brand-name drug, but it is not covered by my Medicare Part D plan. Will the 50% discount on brand-name drugs still apply to this drug when I am in the Donut Hole?
No.  The Donut Hole discount only applies to medications that are included on your Medicare prescription drug plan’s formulary or drug list. If you wish to have your non-formulary medicati . . .

Will all generic drugs get the Coverage Gap discount or only generics drugs in Tier 1 or the lowest formulary tier?
All generics covered on your Medicare Part D plan's Formulary will receive the Doughnut discount.  The discount on generic drugs purchased in the Coverage Gap applies to all generics covered as f . . .

Will the Coverage Gap discount program affect which brand-name drugs are offered under Medicare Part D?
It is possible. The Affordable Care Act limits Medicare Part D coverage for applicable drugs to only those drug manufacturers that have an agreement with CMS to participate and pay discounts under the . . .

I asked my pharmacist about the new discount program and he did not seem to know anything about it. So will I still receive this 50% discount on my refills while I am in the doughnut hole or do I need to find another pharmacy?
Complete Question: I use one expensive medication that cost almost $2000 a month and I have already reached my Doughnut Hole for this year. I asked my pharmacist about the new discount program and he . . .

How much do I have to pay for generics in the donut hole in 2011, 2012, 2013,2014, 2015, etc. until it reaches 25%
Even if your Medicare Part D plan has no coverage in the gap, starting in 2011, you receive a discount on your medications while in the coverage gap. For generic drugs, you would pay the following p . . .

For 2011 you indicate that the full retail cost of drugs while in the donut hole will apply to the amount required to get out for name brands even though I'm only paying 50%. Can you clarify?
Complete Question: For 2011 you indicate that the full retail cost of drugs while in the donut hole will apply to the amount required to get out for name brands even though I'm only paying 50%. I talk . . .

My current prescription drug retail cost are $230 per month. What will be my discount in the Doughnut Hole?
If your total retail prescription medication costs are under $236, you will not exceed your plan's Initial Coverage Limit ($2,840 per year for 2011) and so you will not need to take adv . . .






Advertisement

Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs

Advertisement

Browse Categories
Q&A of the Day
Help! Where Do I Start?
General Medicare Part D (PDPs and MAPDs)
Medicare Advantage Plans (MAPD)
Medicare Supplements or Medigap
Medicare Savings Account Plans (MSA)
Choosing a Medicare Plan
Star Ratings & Medicare Plan Quality
Medicare Part D Enrollment
ANOC: Annual Plan Changes
Changing Medicare Part D Plans
Medicare Enrollment Periods (IEP and AEP)
Special Enrollment Periods (SEPs)
Medicare Plan Disenrollment
Late-Enrollment Penalty (LEP)
Initial Deductible
Cost-sharing: What You Pay
Paying Your Premiums
Extra Help - LIS - Medicaid
IRMAA: Higher Incomes and Costs
Living with Your Medicare Part D Plan
Explanation of Benefits (EOB)
Pharmacies and Part D
Retail Drug Pricing
Straddle Claims
Understanding Your Formulary
Monthly Formulary Changes
Drug Usage Restrictions (QL, PA, ST)
Formulary Exceptions (Coverage Determinations)
Transition Fills
Coverage of Specific Drugs
Diabetes and Diabetic Coverage
The Donut Hole or Coverage Gap
Entering the Donut Hole
Donut Hole Discounts
Closing the Coverage Gap
Exiting the Donut Hole
Catastrophic Coverage
TrOOP and MOOP: Out of Pocket Costs
Specific Healthcare Coverage
Medicare Plan Providers
Traveling with Your Medicare plan
Moving and Medicare Part D
Drug Discount Cards
Using Part D with Other Drug Programs
VA and TRICARE Coverage
Employer Drug Coverage
General Medicare
New Medicare Cards
Medicare Part B
Medicare Set Aside Arrangements
Medicare and the ACA Marketplace
Online Tool Tips
Other Q1Medicare Tips and Questions
$250 Doughnut Hole Rebate (Only in 2010)


Compare Discounted Medication Prices
Prescription Discounts are
easy as 1-2-3
  1. Locate lowest price drug and pharmacy
  2. Show card at pharmacy
  3. Get instant savings!
Your drug discount card is available to you at no cost.




Advertisement



Pets are Family Too!
Use your drug discount card to save on medications for the entire family ‐ including your pets.

  • No enrollment fee and no limits on usage
  • Everyone in your household can use the same card, including your pets
Your drug discount card is available to you at no cost.



Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.