Prescription drugs are an essential for many people covered by Medicare. What you pay for your medications may vary through the year as you move through the different coverage stages of Medicare Part D. The second to last stage of coverage is known as the Coverage Gap or Donut Hole. While you still have some coverage in this stage, it’s important to understand the limitations to avoid unexpected out-of-pocket costs.
Medicare Part D provides coverage for your prescription medications. These plans can be added on to Original Medicare or purchased as part of a Medicare Advantage Plan. The drugs that are covered can vary plan to plan, but Medicare does require all carriers to cover a wide range of medications that enrollees are likely to need. These formulary lists include most drugs in protected classes, like those use to treat seizures and cancer.
Prescription drugs are usually categorized into different tiers. Medications in Tier 1 come at the lowest cost to you, while higher tiers are more expensive. The dividing lines between tiers are unique to each plan, but the general idea is the same. Tier 1 drugs commonly consist of generic prescription medications. Higher tiers include brand-name prescriptions and medications used to treat complex or rare medical conditions.
Medicare Part B covers doctor visits and outpatient care, including:
Doctor visits, including when you are in the hospital
Diabetes screenings, education, and certain supplies
An annual wellness visit and preventive services, like flu shots
Mental health care
Clinical laboratory services, like blood and urine tests
Durable medical equipment for use at home, like wheelchairs and walkers
X-rays, MRIs, CT scans, EKGs and some other diagnostic tests
Ambulatory surgery center services
Some health programs, like smoking cessation and obesity counseling
Ambulance and emergency room services
Physical therapy, occupational therapy and speech-language pathology services
The Donut Hole is a temporary restriction on how much your plan can pay for your prescription drugs. This takes effect after your total prescription drug costs meet the initial coverage limit for the year. In 2022, the initial coverage limit is $4,430. You will pay up to 25% of the total cost for a covered drug while in the Donut Hole stage. You exit the Coverage Gap once you reach $7,050 in prescription costs for 2022.
Medicare counts your plan’s deductible, coinsurance, and copayments toward the initial coverage limit. For people whose Medicare Part D plans have a $0 deductible, only the amount you pay towards your covered prescriptions moves you towards the Donut Hole.
Your monthly Part D premium is not factored into your annual spending totals. Expenses for drugs not covered by your plan also do not count. This applies both to drugs that are excluded from your plan’s formulary, as well as those that Medicare does not allow any of their providers to cover.
Part D Extra Help is designed to offset the cost of prescription drug coverage for Medicare enrollees with limited income. This program lowers the cost that recipients pay for their prescription drugs. People who receive Extra Help are very unlikely to spend enough on their medications in a year to enter the Donut Hole.
Understanding how the Donut Hole works allows you to make educated decisions about your prescription drug spending. One of the best ways to make sure you plan for Coverage Gap expenses is to choose a Medicare Part D plan that is the best fit for you. You can shop plans on your own, or take advantage of our free consultations! You can trust the experts at Senior Insurance Advisors to help you find the best coverage for your needs and your budget.
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