How to avoid the Medicare Part D donut hole

June 6, 2022

Medications account for a big part of healthcare expenses for seniors. At Aspire Health, we receive a lot of questions from our Medicare Advantage plan members about prescription drugs costs and how to avoid the Medicare Part D donut hole. With this in mind, we wanted to explain what the donut hole is, how it works and how you can avoid it to keep your medication costs as low as possible.

What is the Medicare “donut hole”?

The donut hole, more formally known as the coverage gap, is a period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap starts when you and your plan have paid a set dollar amount for prescription drugs during that year. We explain the donut hole in more detail in a previous blog post.

How can I avoid the Part D donut hole?

Here are some steps you can take to slow or avoid your approach to the donut hole each year:

  1. Switching to generic drugs

A generic drug is a medication created to be the same as an existing, approved brand-name drug in dosage form, safety, strength, effectiveness, stability, and quality. They’re sold at a substantially lower cost due to lower research costs, so they could save you money. Remember to always ask your doctor if your prescription is available in generic form.

  1. Confirm if your drug is included on your plan’s drug list (formulary)

In addition to asking if your prescription is available in generic form, always ask your prescribing doctor if the prescription is on your plan’s drug list (formulary). Your formulary might not include your specific drug. However, in most cases, a similar drug should be available.

  1. Shop prices at different pharmacies

When it comes to getting the best price on your prescription drugs, it is always a good idea to shop the prices at different pharmacies. Every pharmacy prices prescriptions differently, and that price can vary with each medication. Pharmacy A might process one drug higher than pharmacy B, but with another drug, pharmacy B may price the drug higher than pharmacy A, and this could affect the total cost of the drug. You will still pay your set copayment, but this could affect when you reach the donut hole or coverage gap.

  1. See if you qualify for the Medicare Part D Extra Help/Low-Income Subsidy (LIS) program

This program helps you pay for a portion of Part D prescription drug plan costs, including Part D premiums, deductibles and copayments. Whether or not you qualify for a full subsidy, or a partial subsidy depends on your income and assets. If you have Extra Help, you’ll see significant savings on prescription drug plans and medications at the pharmacy, and you do not fall into the donut hole. Aspire Health is happy to help Medicare Advantage plan members find financial assistance. Give Member Services a call at (855) 570-1600. TTY users call 711.

Aspire Health’s Medicare Advantage plans all include Part D coverage, and we want to ensure you get the help you need when it comes to maximizing your prescription drug benefits. Call our Pharmacy team and let us know if you need help. We can be reached at (888) 495-3160. TTY users call 711.


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