What Is A Coverage Gap For Medicare Prescription Plans?



The coverage gap for Medicare, which is a concept also known as the Medicare doughnut hole, is a payment and coverage discrepancy that occurs after a person enrolled in one of the various Medicare D Prescription Drug plans has used up their insurance limits, as set forth in the Medicare Guidelines Website, and is forced to temporarily pay for their own medications. This situation results in some uncomfortable feelings centered somewhere around distrust and anger when the person getting their prescriptions realizes the co-pay they are so use to paying temporarily no longer applies.

What Is The Limit?

As a Medicare Part D enrollee you pay a specific amount for your co pay. This amount is determined by the plan you have enrolled yourself into. We will stick with the standard plan as to go into each and every single one of them would require too much time. In the standard plan you as an enrollee pay your deductible until your total drug cost comes to the amount $2,250.

What Happens Afterwards?

Once you have reached this amount you come to the Coverage Gap for Medicare Prescription Plans, or the Doughnut Hole as stated above. While in this hole you will pay the full amount of your prescription drugs until you have paid the amount of $3,600 out of pocket – out of pocket being the amount you pay, like a deductible. According to the Medicare website, what has been paid until here counts towards the $3,600 you are now responsible for.

Do I Get Coverage Again?

After the TROOP (Total true Out-Of-Pocket) expense equals the amount of $3,600 you reach a level known as “Catastrophic Coverage” and your cost per drug drops to a small co-pay which lingers around $5 or a co-insurance payment of 5%, of course it depends on whichever is greater because that is what you will be paying.



Comments are closed.