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2016 Donut Hole Figures

Sep 5, 2015

CMC 2016 Coverage Gap or “Donut Hole” Threshold Figures

Medicare Donut HoleAt the beginning of each calendar year you will typically pay co-payments for each of the prescriptions that you have filled at the pharmacy.  These co-pays can vary in price from $0 for inexpensive “preferred generic” medications to $95 or more for “non-preferred brand” medications or “specialty” medications, depending upon the Part D plan that you are enrolled in.

Although what you will initially pay for co-pays at the pharmacy is certainly significant, it is important to keep track of the negotiated retail price for each of your prescriptions.  Why is this important?   Because the negotiated retail price is what adds up in the background each time you fill a prescription putting you at risk for entering the “donut hole.”

To enter the “Donut Hole” in 2016, the negotiated retail price of your prescriptions will have to exceed $3,310, up from $2,960 in 2015.  The fact that this threshold number has increased is a good thing!  The higher the number the less likely you are to reach it.

Once the retail price of your medications does exceed the donut hole threshold of $3,310, the price you pay at the pharmacy will change from the stated co-pays you were accustomed to and become coinsurance (you will receive a 42% discount off of the negotiated retail price on generic medications and a 55% discount on brand medications.) This is most often times a substantial increase in costs at the pharmacy and you will keep paying this increased cost until your TROOP or True Out-of-Pocket Costs reaches $4,850,

Once your TROOP reaches $4,850 your costs at the pharmacy will dramatically decrease to just 5% or $2.95 for generic drugs and 5% or $7.40 for brand drugs.  These ultimate lower costs may seem nice, but you had to spend quite a bit of money to get there!

Want help staying out of the donut hole?

Make sure you review your Part D plan each year during Medicare Open Enrollment (October 15 through December 7) to make sure you are on the ideal plan for your current list of medications.  Ask your doctor to prescribe generic medications whenever possible.  Ask for samples of brand medications if your doctor has them available.

And stay away from eating donuts!  😉