The Medicare Project   
a consumer's guide to Medicare programs, Medicare Part D Prescription Drug Coverage, the Medicare Gap and Doughnut Hole

topics in this section: Medicare Prescription Drug Gap, Medicare Part D coverage, Medicare Prescription programs, supplement insurance

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The Medicare Coverage Gap in Part D, Medicare "Doughnut Hole"
Web pages and brochures that explain and give help on the issue of the Medicare "Doughnut Hole" Prescription Drug Coverage Gap.

This is one section of The Medicare Project, a series of consumer directories that help seniors through the maze of Medicare information in the hundreds of pages at government and private websites. Our editors have chosen these recommendations to help you find answers to questions about Medicare insurance and coverage. This section focuses on Medicare coverage or insurance issues concerning the infamous Medicare 'Doughnut Hole" gap in prescription drug covereage.

In most cases, Prescription Drug Coverage Stops During The Coverage Gap

Your Medicare Part D prescription drug coverage has a phase when none of your prescription medication costs are paid for by your Medicare plan. This interval is called the Coverage Gap, or "Doughnut Hole". (The word "Gap" is used also to refer to services that are not 100% paid for in Medicare Part A and Part B, including co-pays and deductibles. This article refers to Medicare Part D Prescription Drug Coverage only.)

In the odd structure of Medicare Part D there is, first, a $250 deductible, which means you don't get any help until your drug costs pass $250. Above $250, you must pay 25% of the costs up to $2,000.

When your drug costs total 2,250 you reach the infamous "doughnut hole" -- and coverage generally stops until your prescriptions and drugs reach $5,100, at which point it's coverage starts again and pays 95 percent of any additional costs.

When you buy a Medicare Part D insurance policy --or a Medicare health care policy that includes prescription drug coverage-- you have the option of selecting a policy that will covers all or part of your costs through the coverage gap. As you would expect, this type of coverage costs more than policies that do not provide coverage through the "doughnut hole". (For other Medicare topics, see our home page The Medicare Project - home)

This summary presents general information that applies to most Medicare enrollees, but, as in most government programs, there are always exceptions and variances which could possibily apply to you. Do not use this information as legal or precise advice. See the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD 21244-1850 - www.medicare.gov for the official US government Medicare policies and regulations.

Web pages and brochures from government, education, and non-commercial sites about these subjects:

brochure or publication:
How the Coverage Gap works for People with Medicare Prescription Drug Plans

source:Cornell University (College of Human Ecology) Medicare Part D
file size:4 pg.   languages: English  date:August 2006
from the brochure: "Once a person reaches $2,250 in total drug costs (not including premiums), there is a gap in Medicare’s coverage. While the person is in this coverage gap, the plan will pay nothing toward their drug costs. But the person will pay the drug plan’s discounted rate for their drugs during this time.."

web page:
Seniors Struggle over Medicare Drug Gap Coverage

source:NPR (National Public Radio)
languages: English
from the web page: "Most plans participating with Medicare operate this way; they help people pay for their prescriptions in the beginning but stop paying when costs get higher, and start again when costs reach the catastrophic range. But for seniors on a limited income and with high medication costs, the so-called coverage gap is no small problem...."

web page:
Millions of Seniors Facing Medicare 'Doughnut Hole'

source:washingtonpost.com
languages: English
from the web page: "Millions of older Americans are confronting a temporary break in their Medicare drug coverage this month that will require them to pay the full cost of their prescriptions or face the painful prospect of going without... This is the "doughnut hole"...."
how to use this data

web page:
New York Times Examines Medicare Drug Benefit's Doughnut Hole Coverage Gaps

source:Kaiser Daily Health Policy Report
languages: English
from the web page: [Nov 26, 2007] "The New York Times on Saturday published two articles examining the so-called "doughnut hole" coverage gap of the Medicare prescription drug benefit. In 2008, the coverage gap will take effect when beneficiaries' total drug costs reach $2,510. Beneficiaries then will be responsible for paying 100% of drug costs until total costs reach $5,726, when catastrophic coverage kicks in...


web page:
FIND OUT HOW TO NAVIGATE MEDICARE’S PRESCRIPTION COVERAGE GAP

source:Federal Citizen Information Center of the U.S. General Services Administration
languages: English  date:November 2006
from the web page: "When it comes to Medicare, the term “donut hole” doesn’t refer to one of your favorite breakfast sweets. It refers to the coverage gap that occurs when Medicare temporarily stops paying for your prescriptions and you have to pay the entire cost yourself. Learn how this gap may affect you and your loved ones with the free Medicare Resources package of publications from the National Pharmaceutical Council and the Federal Citizen Information Center..."

brochure:
Bridging the Coverage Gap

source:Congressman Phil Gingrey, M.D.
file size:2 pg.   languages: English  date:August 2006
A publication from CENTERS FOR MEDICARE & MEDICAID SERVICES

web page:
5 Ways to Lower Your Costs During the Coverage Gap

source:medicare.gov
languages: English  date:August 2006
from the web page: "Consider Switching to Generics, Over-The-Counter (OTC), or Other Lower-Cost Drugs; Explore National and Community-Based Charitable Programs; Look into Pharmaceutical Assistance Programs; Look at State Pharmaceutical Assistance Programs; Apply for Extra Help..."
 
also from medicare.gov:
brochure:
2008 Choosing A MediGap Policy: A Guide To Health Insurance For People With Medicare
file size: 56 pg, available also in large print version   languages: English
our comments: ...A Medigap policy is health insurance sold by private insurance companies to fill gaps in the Original Medicare Plan coverage. Medigap policies help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services. Some Medigap policies cover certain costs not covered by the Original Medicare Plan..."

web page:
Medicare Part D 2008 Data Spotlight: The Coverage Gap

source:The Henry J. Kaiser Family Foundation
languages: English  date:August 2006
from the web page: "his data spotlight examines the coverage gap, or “doughnut hole,” in Medicare drug plans available in 2008. Part D enrollees (other than those receiving low-income subsidies) will reach the coverage gap after they incur $2,510 in total drug costs in 2008. At that point, enrollees are required to pay 100 percent of drug costs until they qualify for catastrophic coverage...."

brochure:
Coverage through the “Doughnut Hole” Grows Scarcer in 2007

source:Families USA
file size:12 pg.   languages: English  date:November 2006
from the brochure: "Special Report...Unlike most forms of insurance, the Medicare Part D prescription drug program has a hole in its middle. This coverage gap, colloquially known as the “doughnut hole,” is perhaps the most bizarre and troublesome aspect of the Part D drug program...."

web page:
Tracking Your Drug Payments: What you pay + what your plan pays

source:AARP MedicareRx Plans
languages: English
from the web page: "The coverage gap begins after you and the plan together have spent $2,400 in yearly total drug costs. At this point you will pay 100% of your prescription drug costs until you reach $3,850 in yearly true out-of-pocket drug costs. True out-of-pocket costs, or "TrOOP", are the amounts you pay as your share of your prescription drug costs in a Part D plan, ..."


web page:
Medicare Part D Coverage Gap Can Be a Black Hole for Some Seniors

source:University of California San Francisco, School of Pharmacy
languages: English
from the web page: "In the new United States Medicare Part D prescription drug plan, most people are responsible for 100% of their drug costs after their annual drug expenses exceed US$2,250 and until their expenses reach US$5,100. ..." (Link to news story)

brochure:
MOST ESRD PATIENTS WILL FALL INTO THE MEDICARE “DOUGHNUT HOLE”

source:American Society of Nephrology
file size:2 pg.   languages: English  date:November 2006
from the brochure: "Kidney Patients Face High Drug Costs under Part D Plans...Washington, DC (August 2, 2006) — Medicare beneficiaries with end-stage renal disease (ESRD) are a high-risk group for increased medication costs related to a gap in coverage—the so-called "doughnut hole," or lack of prescription drug benefits between $2,251 and $5,100 in medication expenses—in the Medicare Part D prescription drug benefit, suggests a study in the September Journal of the American Society of Nephrology..."

web page:
Bridging the Coverage Gap: A Tip Sheet for Medicare Patients

source: Pennsylvania Medical Society
languages: English
from the web page: "Many health insurance plans have limits on how much they will cover for prescription drugs. Medicare drug plans are no different. The good news is that Medicare drug plans provide special coverage if you have an unexpected illness or injury that results in extremely high drug costs.

This is called “catastrophic” coverage. It assures that once you have paid $3,850 out-of-pocket for drug costs in a calendar year, almost all of your drug costs above that amount are covered..... "

web page:
Medicare Prescription Drug Coverage Gap - Navigating the "Doughnut Hole" With Patients

source:familydoctor.org (American Academy of Family Physicians)
languages: English
from the web page: "If you don't qualify for extra help, your drug plan may have a "coverage gap" -- some people call it the "donut hole." A coverage gap means that, once you and your plan have spent a certain amount for your covered drugs (up to $2,400), yuou continue to pay your monthly premium and you pay for all of your drug costs out-of-pocket. ..." (Link to news story)

web page:
What is Medi-Gap?

source: Congress of California Seniors
languages: English
from the web page: "A Medicare supplemental policy - Medi-Gap - is a type of insurance that is designed specifically to cover part or all of Medicare's co-payments and deductibles.... "

 

 

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