Medicare Donut Hole

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Medicare drug plans are widely used by older adults. There are many different plans available to people. They can usually find a plan that works best for them and their situation. What a lot of people may not know about is that most of these plans have a coverage gap (also called the “donut hole”). 

When a patient reaches this coverage gap, they are often charged a higher co-pay for their brand name drugs. These plans start over each new year. A lot of patients reach this coverage gap towards the end of the year. The drug plans only allow a certain amount of money spent on drugs each year. For 2021, it will be about $4,100 that the patient and their plan will be able to spend before reaching the coverage gap.  Medications like insulin and inhalers are often expensive. This can lead to reaching the coverage gap sooner than expected. 

If a patient does reach the coverage gap, their co-pay will be no more than 25 percent of the cost of the medication. Some medications may cost $500 a month. Some may cost even more. This can leave the patient with a very high co-pay. Patients are often confused about why their medication has increased so much from last month. The coverage gap is usually the cause. A patient can spend enough to get out of the coverage gap. Often, they must wait until the new year for their prices to return back to normal. 

Patients can work to avoid or limit the time to reach the coverage gap. They need to be aware of how much their medications actually cost. Patients might just look at the co-pay and not realize the actual price. Patients can work with their doctors to try and find different medications that may be cheaper. They can find out if they qualify for extra help in affording their medications. Patients can also work with their pharmacist to find out other cost saving opportunities. They can also find coverage plans that work best for them. 

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