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Closing the prescription drug donut hole in Medicare Part D

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closing donut hole

The Affordable Care Act gradually closes the gap in Medicare drug coverage (Part D) over the next several years until it's closed in 2020. This gap is known as the "donut hole."" The gap in coverage happens after you've already spent money for covered drugs.

Here's how it will work. For brand-name drugs covered by Medicare:

In 2013, you pay 47.5% of the cost when you're in the donut hole. To calculate your exact cost, take the dollar amount you would normally pay for your prescription and multiply it by 47.5%. So if your prescription is $100, you will pay $47.50.

Between now and 2020, you'll pay less and less each year until you pay just 25% of the brand name drug's cost.

You'll also save when you get generic drugs:

In 2013, you pay 79% of the generic drug's cost in the coverage gap.

You'll pay less each year until you pay only 25% of the drug's cost by 2020.

You don't need to do anything to get the discount. It will happen as you fill your prescriptions. Remember to work with your drug plan to make sure that your records are correct.

See what you'll be paying for drugs until the coverage gap is closed in 2020.

Here's what's different

Before health care reform, you may have had to pay the full price for prescription drugs, up to a certain amount, when you were in this gap. Now, the health care reform law is closing the donut hole so your prescriptions are more affordable.

How it impacts you

You'll pay less each year for your prescriptions as the gap in coverage is closed. You get this discount when paying for your medication at a pharmacy or through mail order.

How do I know when I've reached the coverage gap?

The Explanation of Benefits notice, which your drug plan mails to you each month when you fill a prescription, will tell you how much you've spent on covered drugs and whether you've entered the coverage gap.

Who can get the savings while in the coverage gap?

You can get the savings if all of the following are true:

  • You're currently enrolled in a Medicare prescription drug plan (including employer group health and waiver plans) or a Medicare Advantage Plan (like an HMO or PPO) that includes prescription drug coverage.
  • You don't get Extra Help (a Medicare program that helps people with limited income and resources pay Medicare prescription drug costs).
  • You've reached the coverage gap.

What if I don't get a discount and I think I should have?

You can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program or by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

How will I know if my prescription will be covered at a discount?

Contact your drug plan or ask your pharmacist if the prescription drugs you take are covered at a discount during the coverage gap.

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