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FAQs on Entering the Donut Hole



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Category: Entering the Donut Hole


Most Viewed FAQs in Category
What is the Initial Coverage Limit? Can the limit vary between Medicare Part D plan providers?
Your Initial Coverage Limit (or ICL) is the boundary between your Medicare Part D plan's Initial Coverage Phase and the Donut Hole or Coverage Gap.  The ICL is the total retail value of formulary . . .

How can I find out if - or when I will reach my Medicare Part D plan's Donut Hole or Coverage Gap?
Here are 5 ways to see how close you are to your Donut Hole or Coverage Gap. 1.  Call Member Services.You can always call your Medicare Part D prescription drug plan and ask a Member Services . . .

If I enroll in a Medicare prescription drug plan that has an initial deductible, will the deductible impact when I go into the Donut Hole?
No.  Your Medicare Part D plan's Initial Deductible does not affect when you go into the Donut Hole or Coverage Gap.  However, your Initial Deductible will impact how quickly you exit the Do . . .

You say that I will enter my Medicare Part D plan's Doughnut Hole or Coverage Gap when my retail drug costs reach a certain dollar level that changes yearly. What exactly do you mean by "retail drug costs"? Is that what I spend on my pharmacy drugs?
The "retail costs" of medications that are used to calculate when you "fall" into the Coverage Gap or Doughnut Hole are the actual negotiated cost of formulary or Part D plan covered drugs that you ha . . .

When does a Medicare Part D beneficiary enter and exit the doughnut hole or coverage gap? The Doughnut Hole calculators seem to provide an estimate. But how does a beneficiary really know exactly when they enter and leave the coverage gap?
Leaving the Initial Coverage Phase and Entering into the Donut Hole A Medicare Part D beneficiary enters the  Doughnut Hole, Donut Hole  or Coverage Gap when their retail medication costs . . .

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 . . .

I never got a report from my Part D plan showing how close I am to the Donut Hole. Shouldn't I be getting a summary of my prescription drug spending?
Yes, you should receive regular statements on your prescription spending.Medicare Part D plans send out a monthly "Explanation of Benefits" (or EOB) letters to all of their members.  The EOB lett . . .

I currently use two prescriptions and my Medicare Part D prescription drug insurance does not pay anything for either one of these drugs. Does the retail cost of these two medications add into the calculation towards my Doughnut Hole?
No.  If a prescription medication is not covered by your Medicare Part D plan, then the purchase price for this non-formulary drug is not counted toward your Initial Coverage Limit - and is not u . . .

How much would I need to spend per month on prescription drugs before I enter the Donut Hole?
The amount of prescriptions you can purchase before entering the Donut Hole will vary with each year's ever-changing Initial Coverage Limit. For example, you enter the 2018 Donut Hole or Cover . . .

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 . . .

Newest FAQs in Category
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 . . .

What is the Initial Coverage Limit? Can the limit vary between Medicare Part D plan providers?
Your Initial Coverage Limit (or ICL) is the boundary between your Medicare Part D plan's Initial Coverage Phase and the Donut Hole or Coverage Gap.  The ICL is the total retail value of formulary . . .

If I enroll in a Medicare prescription drug plan that has an initial deductible, will the deductible impact when I go into the Donut Hole?
No.  Your Medicare Part D plan's Initial Deductible does not affect when you go into the Donut Hole or Coverage Gap.  However, your Initial Deductible will impact how quickly you exit the Do . . .

My Medicare Part D plan told me that I will go into the Donut Hole based on what I paid for my medications plus what the insurance company paid. Is this true?
Yes.  You will enter the Donut Hole or Coverage Gap portion of your Medicare Part D plan when the total "retail cost" of your medication purchases exceeds your plan’s Initial Coverage L . . .

Does my $47 co-pay impact when I enter the Donut Hole?
No.  You will enter the Donut Hole based on the retail value of your formulary drug purchases - not your co-payment.So if your Tier 3 medication has a negotiated retail cost of $300 and you have . . .

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 . . .

How much would I need to spend per month on prescription drugs before I enter the Donut Hole?
The amount of prescriptions you can purchase before entering the Donut Hole will vary with each year's ever-changing Initial Coverage Limit. For example, you enter the 2018 Donut Hole or Cover . . .

I currently use two prescriptions and my Medicare Part D prescription drug insurance does not pay anything for either one of these drugs. Does the retail cost of these two medications add into the calculation towards my Doughnut Hole?
No.  If a prescription medication is not covered by your Medicare Part D plan, then the purchase price for this non-formulary drug is not counted toward your Initial Coverage Limit - and is not u . . .

How can I find out if - or when I will reach my Medicare Part D plan's Donut Hole or Coverage Gap?
Here are 5 ways to see how close you are to your Donut Hole or Coverage Gap. 1.  Call Member Services.You can always call your Medicare Part D prescription drug plan and ask a Member Services . . .

I never got a report from my Part D plan showing how close I am to the Donut Hole. Shouldn't I be getting a summary of my prescription drug spending?
Yes, you should receive regular statements on your prescription spending.Medicare Part D plans send out a monthly "Explanation of Benefits" (or EOB) letters to all of their members.  The EOB lett . . .






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