Medicare - How to Navigate the Part D Coverage Gap

Some tips and information to help navigate the Part D coverage gap.

  • The Part D coverage gap is also know as the “Donut Hole!”
  • The Part D coverage gap is a payment stage with Medicare prescription drug plans when the main cost burden for prescription drugs shifts from the insurance plan to the plan member.
  • There are 4 different stages you need to be aware of:
    • Deductible Stage (You pay the full amount of your drugs until you satisfy your annual prescription deductible amount)
    • Initial Coverage Stage (You pay your plan’s copay or coinsurance for the specific tier levels of each of your drugs)
    • Coverage Gap Stage (You pay a higher percentage amount of your drug costs until you reach the next stage.)
    • Catastrophic Coverage Stage (After reaching this stage, you pay a reduced amount for your drugs until the end of the year. Then you start the cycle all over again.)
  • Each of the above Part D payment stages (except the last) has a dollar limit that marks when you exit that stage and enter the next. You move through the Part D payment stages based on how much is spent on your drugs throughout the year.

Tips for Navigating the Coverage Gap

It’s best to avoid the coverage gap all together, if you can! 

Plan ahead by getting an estimate of the following:

  • Try to determine what your yearly drug costs may be with your Part D plan
  • Try to determine if (and also when) you might reach the coverage gap
  • Try to determine when you would exit the coverage gap. 

Your out-of-pocket drug costs are reduced once you’re out of the gap and in the catastrophic coverage stage.

Search your plan choices.

Talk to your doctor about your options for using generic or low cost drugs rather than brand name or high price drugs. Make sure to ask your doctor about this and other ways to lower your drug costs. If you enter the coverage gap, your doctor may help you find ways to get through quickly. Your costs will be much lower once you reach the catastrophic payment stage.

Track your drug costs. Your plan should send you a statement each month that gives you important information. It’s called an Explanation of Benefits. This statement lists the prescriptions you filled that month with details about what you paid, what your plan paid and any other payments on your behalf from programs or organizations.

Ask for help. There are programs and organizations that may be able to help if you can’t afford your medications, no matter what payment stage you’re in. Usually you need to qualify based on your income and other financial resources.

Note: Medicare Insurance information can be overwhelming and confusing to many people. As an independent licensed agent I can explain things to you in simple terms so you feel comfortable making a decision. Then I can help you choose and enroll in a plan that you feel fits your needs.

By the way, it doesn’t cost you any more if you enroll in a Medicare Insurance plan through me as an independent agent versus directly with an insurance company either over the phone or via the Internet, since I get paid by the insurance companies for your enrollment. Plus you will have personalized service by a local agent. If you would like my assistance, please call me at 941-404-5334.

By calling this number, I understand I will be directed to a licensed insurance sales agent.

Please take a few seconds to read what my actual clients have to say about my personalized service in their own words by clicking this link. Insurance Agents ReviewsTips for Navigating the Coverage Gap