The Medicare donut hole, as known as the Medicare Part D donut hole or the Medicare Part D coverage gap, is the difference between what your standard insurance covers for your medications and the point when seniors enter what is known as the ‘catastrophic coverage threshold.’

I am going to explain this entire process to you, in as simple a manner as possible, so that you can understand not only the government process but also to give you tips and techniques so that you can avoid paying too much for your prescription medications.

Video Overview of the Medicare Donut Hole

Out-Of-Pocket Expenses Before The Coverage Gap

First of all, if you make the choice to join a Medicare Part D prescription drug plan, you will have to pay an initial deductible for your medications. This number varies from year to year but currently it is $310.

While you are covered during this initial phase, you do not have to worry about the Medicare donut hole. You simply make the co-payments that are required on your prescriptions and the Medicare Part D drug plan that you selected by its share.

This initial coverage lasts until both you, through your deductible, and the insurance company have combined to pay out $2,840 for your prescriptions [once again, this number changes from year-to-year so it is important for you to check].

When The Donut Hole Hits

Once this $2,840 limit is reached is when the problems begin. You are now in the Medicare donut hole. This means that you now have to pay the full cost of your medications, until you reach a total out-of-pocket expense of $4,550 [and yes, this changes year-to-year as well].

After the $4,550 limit, the Medicare donut hole ends, and your prescription drug plan will pay most of the costs of your medications FOR THE REMAINDER OF THE YEAR! This is the ‘catastrophic coverage limit’ where you only pay a small co-payment for your medications.

Now, perhaps the biggest single misconception out there when dealing with the Medicare donut hole is that once you enter the catastrophic coverage limit, you are there forever.

People are under the misconception that they will NEVER have to pay a significant amount for their medications again.

I am sorry to say this to you but that isn’t the case. What happens is that you are in the ‘catastrophic coverage threshold’ only for the remainder of the year, and then the entire process starts over on January 1st.

So this means that dealing with the Medicare donut hole will be annual event, unless you come up with the ability to find ways to avoid the coverage gap.

Tips and Ideas To Avoid The Coverage Gap

Pharmacy Discount Card 

The StuffSeniorsNeed Pharmacy Discount Card can provide significant relief for those who are dealing with the donut hole.  You can save up to 80% off of your prescription medications.

You can download your own card for free right here.

Generic drugs and alternatives with your doctor

Generic drugs are just as safe and effective as brand name drugs. And this isn’t me saying this…it’s the FDA. (See my blog post regarding generic drugs here.)

So if you have the ability to obtain the same active ingredient at a cheaper price this will save you money and help you to avoid the Medicare donut hole.

In addition, speak with your doctor regarding the medications that he/she is prescribing. Your doctor may be able to prescribe lower-cost medications as well.

See If Your State Has A State Pharmaceutical

Assistance Program (SPAP)

These were once popular, but since the Federal government took over the prescription drug benefit with Medicare Part D and with the financial problems that many states are facing most states have discontinued their involvement in these programs.

The Federal Medicare website has an interactive feature that will let you browse the states that have still offer such as program. You can visit the Medicare SPAP page by clicking here.

Look Into Private Prescription Drug Assistance

Programs

These patient assistance programs are offered by the manufacturers of the medications, and eligibility is based upon your finances and other criteria which may vary from drug company to drug company.

You may have to do some research but it certainly pay off. Just as an example, I did a Google search for “Lipitor Prescription Drug Assistance Program” and found RXAssist.

They have a comprehensive listing of Prescription Drug Assistance Programs that will help you to avoid the Medicare donut hole by enabling you to obtain your medication at a reduced cost.

National and Charitable Foundations

There are dozens of organizations available to help. One place to find them is at BenefitsCheckUp.org.

Here, you can find assistance not only in paying for food but also to find local organizations that will assist you with your prescriptions drugs and avoiding the Medicare Donut Hole.

Apply For Extra Help

If you already have Medicare and are on a limited income, then you can apply for Medicare Extra Help. This is a special program for those who are low-income and having difficulty paying for their prescription medications.

Lose Weight

And finally, this may not be the type of advice you were looking for, but for most people, if they were to lose 20-30 pounds [or more] to get in better shape you would in all likelihood be able to reduce/eliminate certain medications that you are currently taking.

Therefore, I cannot recommend enough a program of diet and exercise to improve your health so that you can lose weight and take fewer medications. 

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