What is the donut hole?
Posted February 19, 2018
When you go to the pharmacy to fill a prescription, you might pay a copay or coinsurance (percentage of the total cost of the drug). The copay or coinsurance, called cost sharing, is based on the drug tier that drug is in and your plan's Part D drug coverage. Typically, your plan then covers what you do not pay.
Set by Medicare, there are stages for your prescription drug coverage. Stage 3 is called the coverage gap, also known as the donut hole. This means there is a temporary limit on what the plan will pay for prescription drugs.
Not everyone will enter the coverage gap. You will enter the coverage gap after you and your plan have spent a certain amount for covered drugs. This includes the copay or coinsurance you pay when you pick up the prescription, and then what your plan pays for the remainder of the drug. These amounts are set by Medicare, and they can change from year to year. Click here to learn more about the donut hole.
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