In the past, you were responsible for a higher percentage of the cost of your drugs. Although the donut hole has closed, you may still see a difference in cost between the initial coverage period and the donut hole. This amount is made up of what you pay for covered drugs and some costs that others pay.
During this period, you pay significantly lower copays or coinsurance for your covered drugs for the remainder of the year. The issue with the donut hole is that many people in the United States stop taking their medications upon reaching the donut hole because they cannot afford to pay the high costs for the drugs.
They often have to pay thousands of dollars for prescription drugs until they cross this coverage gap. However, for many people in the U. Lawmakers have passed legislation that has slowly helped to close the donut hole, such as the Affordable Care Act.
However, people still experience changes in their coverage as they spend on their prescription drugs. Coverage ends once a person reaches their financial limit on drug spending and starts again during catastrophic coverage. The changes that Medicare are making aim to reduce the costs that people incur while they are in the donut hole.
In , the government took several actions that started to close the donut hole. These included:. The aim of these changes was to make drugs more affordable once a person reached the donut hole, which would encourage people to continue taking their medications and reduce the risk of a break in treatment.
As of , prescription drug coverage takes the following shape:. Ideally, these changes will allow a person to have long-term access to the medications their doctor prescribes.
Here is an example of process of how a Medicare user crosses the donut hole and reaches catastrophic coverage in You will not find true exceptions to the Medicare donut hole, but a federal prescription drug assistance program is available for people with Medicare Part D.
This program is known as Extra Help , and it keeps you from being subjected to the coverage gap. This is an income-driven program that not everyone will qualify for. Apart from federal- and state-funded programs, private options are available to help cover you while you are in the gap. To find the best fit for you, you will want to thoroughly compare plans and ask for a free quote before deciding on an option.
By subscribing you agree to the Terms of Use and Privacy Policy. Health Topics. Health Tools. These plans work similarly to standard Part D plans. Thus, they still involve coverage gaps. Using lower-cost drugs, like generics or similar drugs, will substantially lower your costs. It pays to have donut hole assistance like Extra Help or a state pharmacy assistance plan that can pay a portion or all your costs while in the gap.
We understand that the donut hole is a confusing topic and we hope we helped you make sense of it. Many people with or without current prescription drug coverage have questions. Luckily, we're not only a Medicare education resource center — we can also help find the best coverage for you. Having Part D as soon as you're eligible for Medicare will ensure you don't incur a Part D late enrollment penalty. Call the phone number above to speak with an agent about your options.
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Since the inception of his first company in , he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare. Hi DJ!
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