Atlanta Financial Newsroom

Down The Donut Hole: The Medicare Coverage Gap

AFA
October 23, 2018

One of the most confusing Medicare provisions is the prescription drug coverage gap, often called the “donut hole.” It may be clearer if you consider the gap within the annual “lifecycle” of Medicare Part D Prescription Drug Coverage. This also applies to drug coverage that is integrated into a Part C Medicare Advantage Plan.

Annual deductible. Prescription drug plans typically have an annual deductible not exceeding $405 in 2018. Before reaching the deductible, you will pay the full cost of your prescriptions, although you may receive negotiated discounts.

Initial coverage period. After you meet the annual deductible, your plan will pay a portion of your prescription drug costs, and you will typically have a co-payment or coinsurance amount. A 25% coinsurance amount is the standard coverage required by Medicare, but most plans have different levels or “tiers” of co-payments or coinsurance for different types of drugs.

Coverage gap. When you and your plan combined have spent a specified amount on drugs for the year ($3,750 in 2018), you enter the coverage gap. In 2018, you pay 35% of your plan’s price for covered brand-name prescription drugs and 44% of the price for generic drugs. The gap is closing over the next two years (see chart).

You remain in the coverage gap until you reach an annual out-of-pocket spending limit ($5,000 in 2018). Spending that counts toward the limit includes your deductible, copay, and coinsurance; the manufacturer’s discount on brand-name drugs in the coverage gap; and your out-of-pocket payments in the gap. It does not include your premiums, the amount the plan pays, or your payments for non-covered drugs.

Catastrophic coverage. Once you have reached the out-of-pocket limit, you receive catastrophic coverage with much lower payments. In 2018, you would pay the greater of 5% of drug costs or $3.35/$8.35 for each generic and brand-name drug, respectively.

Some plans have more generous coverage in the gap. You may be able to avoid the coverage gap by using generic medicine, when appropriate, to lower your drug costs.

For more information, see Medicare.gov.

 

 

Share This:

Share on facebook
Facebook
Share on linkedin
LinkedIn
Share on twitter
Twitter
Share on google
Google+

We Welcome Connolly Crowley with Lots of Love!

We are excited to announce Connolly Elizabeth Crowley, daughter of Charles and Erin Crowley, was born on June 21, 2019! Weighing in at 7lbs.,15oz., Connolly makes Charles and Erin the parents of two beautiful children; Connolly is Charles and Erin’s second child…

Read More »

Is a Health Savings Account (HSA) Right for Me?

At AFA, we hear our clients express concerns about two financial challenges more often than any others:
• Will I be ready to retire with the lifestyle I want?
• What can I do to protect myself from rising health care costs now and in the future?

Did you realize there is a single vehicle that can help you make progress in both areas? It’s called a health savings account (HSA), which is a government-regulated savings account that combines many of the tax benefits of a Flexible Spending Account and a 401(k), including:
• Your contributions to the plan are pre-tax (if offered through your employer) or tax-deductible (if established on your own). If funded through your employer’s plan, you also don’t pay FICA on the contributions, putting an extra 7.65% back in your pocket.
• Withdrawals for qualified medical expenses are tax-free (more about that below).
• The balance in your plan (that you don’t spend for medical expenses) grows tax-deferred and can be rolled over from year to year, supplementing other retirement savings.

Read More »

Understanding (and Avoiding) Lifestyle Creep

Over the years we’ve seen plenty of research and studies claim that increases in income don’t correspond to increases in happiness. One such survey, using data from the Gallup World Poll, found that the optimal household income for emotional well being was between $60,000 and $75,000 per year. The research shows that beyond that threshold, the correlation between income and happiness flattens pretty dramatically. For many Americans – especially young professionals just getting started in their careers – this may seem like a bogus finding, but by going beyond the headlines we learn that a common reason for that drop-off in financial satisfaction is lifestyle creep.

Read More »

Yearly Archive

Author Archive