The Donut Hole (or Coverage Gap) is a
term used to describe a "gap" or pause in your Medicare Part D prescription drug coverage where - prior to 2011 - you were 100% responsible for the cost of your prescription drugs -
unless your Medicare Part D plan provided additional coverage while in the Donut Hole.
So between 2006 and 2010, the Medicare Part D Coverage Gap or Donut Hole was actually similar to a second deductible in an insurance policy where, after receiving a certain level of drug coverage, you were, once again, responsible for paying your own drug coverage until you reached the Catastrophic Coverage
portion of your Medicare Part D plan or Medicare Advantage plan that included drug coverage (MAPD). In other words, you had a "hole" in the center of your Medicare Part D coverage.
However, with the introduction of the Donut Hole discount
in 2011, you are now responsible for only a portion of your own drug coverage in the Donut Hole.
2020 and beyond: Closing the Donut Hole
In 2020, the Coverage Gap was considered "closed" when both formulary generic and brand-name drugs cost Medicare Part D plan members 25% of the retail drug price (so you will pay $250 for a medication with a $1,000 retail cost) until reaching Catastrophic Coverage where you will pay around 5% of retail.
For example, if your Medicare Part D plan follows the standard Medicare Part D
prescription drug plan, you will pay a fixed 25% cost-sharing in the
Initial Coverage phase and then, if you enter the Donut Hole
, you will
continue to pay the same 25% co-insurance for all formulary drugs
purchased - and since there is no change in coverage between being your
Initial Coverage phase and Coverage Gap - the Donut Hole appears to be
closed (see the diagram below).
The Donut Hole actually closed a little earlier than planned.
In 2018, President
Trump signed the Bipartisan Budget Act of 2019 (Pub.L. 115-123
) that effectively "closes" the Coverage Gap for brand-name drugs, with the brand-name Donut
Hole discount increasing to 75% in 2019 (one year earlier than planned). The Coverage Gap for generic drugs
was not affected by the Act and "closes" as planned in 2020 when all generic formulary drugs will also receive a 75% discount.
Question: So did the Donut Hole just go away from our Medicare Part D plans?
we say that the Donut Hole is now "closed"
since you receive a 75%
discount on all formulary drugs if you enter the Donut Hole - it is possible that the cost of your formulary medications can increase, decrease, or stay the same
once you are in the Donut Hole (Coverage Gap) - depending on your
Medicare drug plan, your initial cost-sharing, and the drug's retail
For example, if you usually pay a fixed co-pay for your drugs (for
example, $47 for a $300 drug) during your Initial Coverage phase, you will pay 25% of $300 if you enter the
Donut Hole or $75. So, you would pay more in the Donut Hole ($75) than
you did in your Initial Coverage phase ($47).
You can click on our FAQ "Did the Coverage Gap or Donut Hole just close up and go away?
" to read more.
Help with planning for your Donut Hole
To help you visualize the phases of your Medicare Part D prescription drug plan coverage, we have a Donut Hole Calculator or PDP-Planner
online illustrating the changes in your monthly estimated costs based on the established standard Medicare Part D plan limits mentioned above.
We also have several examples online to help you get started with PDP-Planner. You can click here for a 2021 example
of a Medicare beneficiary with relatively high monthly prescription drug costs of $800 per month
resulting in estimated annual out-of-pocket costs of $2,731
- you can then change the monthly drug cost to whatever you wish to estimate your out-of-pocket cost.