The Coverage Gap (Donut Hole) | Dave Silver Insurance | Florida's Medicare Enrollment Specialist

The Coverage Gap (Donut Hole)

This is a part of Medicare that most people do not understand.

When you have a prescription drug paln either through a Medicare Advanatge plan or through a stand alone Part D drug plan that you purchase, you have coverage limits.

In 2015 you are covered for the first $2960. What applies to this figure is the actual retail cost of the prescription you are purchasing, not the co pay. So if you have a prescription that has a $25 co pay, the $25 DOES NOT apply towards the $2960. What applies to the actual $2960 is the actual retail cost of the medicine, based on your pharmacy’s negotiated price with the insurer. So under this example, this drug has a retail cost of $200, your coverage limit under your drug plan will drop to $2760.

Once your coverage limit drops to $0, you are in the “coverage gap” or “donut hole”. They mean the same. If you take very expensive medications, getting into the gap will be likely.

If you get into the coverage gap in 2015, you will have to pay 45% cost of your named brand medicine and 65% of the cost of your generic medicine.

By 2020, the “coverage gap” is supposed to be phased out.

Call me and we can go over your prescriptions and see if and when you will get into the “gap”. We can also go over options to avoid this from happening or at least delaying it to to as late in the year as possible. Because every January, the numbers reset and you start all over.

WE’LL ANSWER YOUR MEDICARE QUESTIONS

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