What Is the Medicare Donut Hole?

Who doesn’t love a good donut?

Sugary, sweet, and perfectly fluffy, donuts are a rich indulgence, whether you’re eyeing one for breakfast or dessert.

All right, so by now you’re probably picturing a classic donut, right? Maybe one covered in pink icing, with a beautiful scatter of sprinkles on top? Can you see it in your mind’s eye? Great! Now, concentrate your attention on the center of that donut—right where the hole is.

That’s where our focus is today. Because for millions of Medicare beneficiaries around the country, the empty space of that donut hole is anything but appetizing.

What Is the Medicare Donut Hole?

So, what does the donut hole have to do with Medicare?

Most Medicare drug plans have a coverage gap, which industry professionals tend to call the donut hole.

Once a Medicare beneficiary hits their Medicare coverage gap, or donut hole, they will face a temporary limit on what their drug plan will pay for eligible medications.

In other words, after you and your Medicare prescription drug plan have spent a certain amount of money on covered prescription drugs, you will have to pay your drug costs out of pocket, until you hit a certain yearly limit. At this point, coverage kicks back in, and the gap ends.

While you’re in the coverage gap, your yearly deductible, coinsurance, and copayments all count toward your limit. The amount you pay for your covered prescription drugs also counts toward getting you out of the hole; similarly, any discount paid by drug manufacturers counts as out-of-pocket spending, helping to get you out of the coverage gap.

Your drug plan’s premium, however, will not count toward your limit. Neither will pharmacy dispensing fees, or the amount you pay for drugs that are not covered under your plan.

Are There Steps You Can Take to Avoid the Coverage Gap?

Many Medicare recipients never end up having to face the donut hole, particularly those who qualify for Extra Help for Part D.

For everyone else, there are certain steps you may be able to take to help avoid reaching the coverage gap, or lessening its effects once you’ve hit it, like:

  • Comparison shop at local pharmacies to see if any offer the prescriptions you need at a reduced cost
  • See if your plan offers preferred pharmacies. Preferred pharmacies tend to have lower copayments or coinsurance rates than standard pharmacies.
  • Purchase medication at a discount by ordering your supply through the mail (an option with some prescription plans)
  • Inquire if your prescriptions have generic versions, which tend to be less expensive
  • Seek out a new drug plan

That last point may be particularly worth considering! There are Medicare Part D prescription drug plans that offer benefits in the coverage gap that are far above and beyond what original Medicare may cover.

How a Medicare Supplement Plan Can Help You Fill In the Gap

Many people don’t realize that they have options when it comes to Medicare, including their prescription drug coverage!

There may be alternative and supplemental plans available in your area that offer the right benefits for your needs, including providing additional coverage in the gap.

Medicare supplement plans, also called Medigap plans, are often considered to be the gold standard in coverage by doctors, hospitals, and Medicare recipients. These private health insurance plans are designed to help pay for the healthcare costs that original Medicare does not cover, like copayments, coinsurance, and deductibles.

Supplemental coverage helps give millions of older adults better peace of mind when it comes to the predictable, and unexpected, costs of their medical care.

Even better, the right plan may be able to help you save thousands in out-of-pocket medical expenses, which you could put toward:

  • Keeping your lifestyle intact
  • Enjoying your major life goals in retirement
  • Safeguarding your financial legacy for your family

Have any more questions about Medicare, the donut hole, or supplemental coverage? Well . . .

The Enrollment Specialists Can Help!

Led by our founder and principal consultant, Matt Peebles, the Enrollment Specialists can make figuring out Medicare insurance as sweet as biting into your favorite kind of donut!

There’s a reason why Matt is recognized in the top one percent nationally of all health insurance producers, with hundreds of happy clients around the country! Matt doesn’t believe in cookie-cutter care, and he’ll work with you to customize the insurance policy that will work best for your needs, making sure your costs are minimized and your coverage it at its peak!

And with Matt on your side, you won’t need to bother with the hassles of call centers, online chat rooms, or canned responses! You’ll always be able to get a hold of this health insurance superhero, right when you need him most.

Want to find out when you may hit a donut hole in your current Medicare plan? Ready to say, “I Got A Guy!” for all things Medicare? Don’t hesitate to get in touch today!

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