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FAQs on Donut Hole Discounts

Browse the Most Viewed and Newest Medicare Part D FAQs
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Category: Donut Hole Discounts

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 . . .

If the total cost of one drug purchase takes my annual cost over my Medicare plan's coverage limit and into the Donut Hole, will I pay the copay for my drug plus the discounted cost that is over the coverage limit?
Yes, you are responsible for the co-payment of the purchase plus the amount of the purchase that exceeds your Medicare Part D plan's Initial Coverage Limit ($3,750 in 2018).  However, in such a s . . .

What will I pay for my $250 brand-name drug when I reach the Donut Hole and Catastrophic Coverage phases of my Medicare Part D drug plan coverage?
You will pay $62.50 in the 2019 Donut Hole or Coverage Gap and $12.50 in the Catastrophic Coverage phase for a brand-name drug with a $250 retail value. Once the total retail value of your Medicare . . .

What do I pay when the purchase of my medications moves me from my regular coverage into the Donut Hole? Do I get coverage from my plan or do I receive the Donut Hole Discount?
Both.  When you purchase your medications, the total drug costs can move you from one part of your Medicare Part D plan into another part of your coverage.  For instance, you will move from . . .

If I reach the Coverage Gap and get a Donut Hole Discount on my brand-name drugs purchases, do I still get full retail credit toward meeting my Donut Hole exit point?
No, not quite full retail credit - but credit 85% of the retail cost.  If you exceed your Medicare Part D prescription drug plan's Initial Coverage Limit ($3,750 in 2018) and enter the Donut Hole . . .

Does the Donut Hole Discount apply to a retail drug purchase that straddles my Medicare Part D plan's Initial Coverage phase and the Coverage Gap? In other words, does the Donut Hole discount apply to a Straddle Claim?
Yes.  But, the discount is only for the portion of your drug purchase that carries over into the Coverage Gap.If the negotiated retail price of your medication purchase moves you from your Medica . . .

Will monthly Medicare Part D premiums increase due to the manufacturer's discount on brand-name drugs purchased in the Coverage Gap?
Yes, in 2010, the Congressional Budget Office forecasted a premium increase. The Congressional Budget Office (CBO.gov) issued the following statement: “The Patient Protection and Affordabl . . .

Which brand-name prescription drugs are eligible for the Coverage Gap or Donut Hole discount?
All brand-name Medicare Part D drugs.  According to the Affordable Care Act, only those brand drugs from manufacturers who have agreed to participate in the Doughnut Hole discount program can be . . .

I'm trying to figure out when I will go in the 2011 donut hole. Also, my brand name Rx costs about $1800 a month. In the Donut Hole will the $1800 go toward my out of pocket costs (TrOOP) - or will I only get a credit for my 50% discount or $900?
You will go into the 2011 Donut Hole or Coverage Gap when the total retail cost of your prescription purchases reaches $2,840 - this is your Medicare Part D plan's Initial Coverage Limit.  So if . . .

I am enrolled in a Medicare Part D plan and just entered the Donut hole. Now my Medicare drug plan said that I couldn't get a brand-name drug discount on one of my formulary medications because it was not on the list of eligible drugs. How can that be?
Your medication may be in a generic form.  The 52.5% Donut Hole discount is only for brand name medications (that are included on your Plan's formulary). Medicare Part D beneficiaries in the . . .

Newest FAQs in Category
What discount will I receive for my tier 5 specialty drugs when I am in the Medicare Part D Donut Hole?
It depends on the drug.  The formulary drug tier (such as a Tier 5 Specialty Drug) does not affect your Donut Hole discount.Instead, the discount you receive on your medications when reaching the . . .

Will my drug cost increase when I enter the Donut Hole?
Maybe.  As you move from your Initial Coverage Phase into the Coverage Gap, your savings -- or extra cost -- in the Donut Hole or Coverage Gap will depend on your Medicare Part D plan’s ini . . .

If I receive Medicare Part D Extra Help, will I enter the Donut Hole?
No.  If you are qualified for the Medicare Part D Extra Help program or Low-Income Subsidy (LIS), then you will never enter the Donut Hole or Coverage Gap and the cost of your prescriptions wil . . .

Do I get the Donut Hole discount if my Medicare plan includes Gap Coverage?
Yes - but only the 50% pharmaceutical industries discount for your 2018 brand-name drug purchases (or 70% in 2019).  If your Medicare Part D plan (PDP) (or Medicare Advantage plan (MAPD)) includ . . .

Do I get a Donut Hole discount on my non-formulary drug purchases and will these costs count toward getting out of the Donut Hole?
No.  Only Medicare Part D prescription drugs found on your formulary receive the brand-name or generic Donut Hole discount. Non-formulary medications, over-the-counter (OTC) drugs, and medicati . . .

I already reached the Donut Hole, but I am not sure I received the Donut Hole discount on my last prescription purchase. Is the discount always applied automatically?
Yes. The Donut Hole discount is applied automatically at network pharmacies when you buy formulary medications while in the Coverage Gap.For instance, in 2018, you will see a 65% discount applied to . . .

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 . . .

I was told by a Medicare plan representative that all of their Medicare drug plans have Donut Hole coverage. Is that possible?
Yes, if the plan representative was referring to the Donut Hole discount rather than actual Donut Hole coverage.  Although not all Medicare Part D plans have additional Donut Hole coverage f . . .

Which brand-name prescription drugs are eligible for the Coverage Gap or Donut Hole discount?
All brand-name Medicare Part D drugs.  According to the Affordable Care Act, only those brand drugs from manufacturers who have agreed to participate in the Doughnut Hole discount program can be . . .

I use a brand-name drug, but this medication is not covered by my Medicare Part D plan. Will the brand-name discount 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 plan’s formulary. If you wish to have your non-formulary medication covered by your Medicare Part D pla . . .


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