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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?

Category: Entering the Donut Hole
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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 Limit.  This "retail cost" figure is a combination of what you pay for you your medications plus the portion paid by your Medicare Part D plan.

For example, if you buy a medication at your local pharmacy that has a retail cost of $100, you will pay your plan’s co-payment or cost-sharing, maybe $30, and your plan will pay $70 or the balance of the $100 retail cost.  From this example purchase, the total retail cost of $100 is counted toward meeting your plan’s Initial Coverage Limit (ICL).

So once you have purchased medications with a retail value over your Medicare Part D plan's ICL, you enter your Medicare Part D plan’s Donut Hole.

Please remember that your Medicare Part D plan’s Initial Coverage Limit can change every year.  You can click here to see how the Initial Coverage Limit has changed since 2006.


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