What is MN Medicare Part D Prescription Drug Donut Hole?

admin | August 6, 2015

MN Medicare Part D Prescription Drug donut hole explanation:


The cost of Medicare Prescription Drugs here in Minnesota can get pretty expensive, especially if you are someone who enters the coverage gap, or "donut hole", of their Part D Prescription Drug Plan. However, there is prescription drug cost help during this period that many Medicare member may not be aware of. The Affordable Care Act includes benefits to make your Medicare prescription drugs more affordable.


What is the Part D coverage gap, or "donut hole"?


The Part D coverage gap (“donut hole”) in your Medicare Prescription Drug Coverage is the point at which the retail cost of your covered medications reaches a certain dollar amount. For 2015, that amount is $2,960. This limit increases every year. The combination of what you have paid ̶̶ deductible, copays, co-insurance ̶ and what your Minnesota Medicare Part D Prescription Drug Plan (PDP) has paid gets you to this dollar figure. Once you reach this point, then you are technically responsible for the full cost of all of your covered medications until you have paid out a Total Retail Out-of-Pocket (TROOP) of $4,700 for 2015. If this amount is reached, then you enter the catastrophic phase of the coverage where all of your covered drugs cost you 5%, at most. What is often confusing for Medicare beneficiaries is that the starting point for the member in paying out the total $4,700 is not the $2,960. The Medicare member begins at the amount that they have paid of the $2,960. The amount that the Medicare Prescription Drug Plan has paid is not included.


Is there any help for the prescription drug costs during the Part D coverage gap?


Yes. In 2015, Medicare will pay 35% of the price for generic drugs during the coverage gap. You’ll pay the remaining 65% of that price. What you pay for generic drugs during the coverage gap will decrease each year until it reaches 25% in 2020. Also, through an arrangement between the Center for Medicare and Medicaid Services (CMS) and the drug manufacturers, there is a 50% discount on covered brand-name drugs when you buy them at a pharmacy or order them through the mail. The Prescription Drug Plan kicks in an additional 5%, so you only pay 45% of the retail cost of your covered brand-name drugs during the "donut hole". Furthermore, over time, the coverage gap will close by maintaining the 50% discount the manufacturers offer, and increasing what Medicare drug plans cover. Be aware that the entire cost of covered non-generic and non-brand drugs, or "specialty" drugs, is still 100% the responsibility of the Medicare member during the coverage gap.


How will you know if you have reached the Part D coverage gap?


If the Minnesota Medicare Prescription Drug Plan that you have has a coverage gap ("donut hole"), the plan will mail you an Explanation of Benefits (EOB) notice each time you fill a prescription. This notice will tell you how much you’ve spent on covered drugs and if you’ve reached the coverage gap.


With the benefits provided by the Affordable Care Act and Medicare, the "donut hole" is not nearly as frightening or devastating as many Medicare beneficiaries have come to believe it to be. For more guidance as to how the Medicare Part D coverage gap may affect you and the best Minnesota Medicare insurance plans to limit your prescription drug costs, please contact one of the Medicare specialists at Minnesota Health Insurance Network.

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