Many Part D plans have a coverage gap, also known as the “donut hole.” If your plan has a coverage gap, your plan will stop covering your prescription costs after you reach a certain dollar amount. You will have to pay more for your medications while you are in the coverage gap. When your prescription costs hit the end of the coverage gap, your Part D plan will start covering your medications again.
The standard coverage gap for 2017 starts after you and your plan spend a total of $3,700. Then you will have to pay 40% of brand name prescription costs and 51% of generic prescriptions costs until the total cost of your prescriptions is $7,425.
After your drug costs have reached $7,425, your plan will begin covering your medications again, and your copay will be about 5% of the cost.
Some plans don’t have coverage gaps. Some plans that have coverage gaps have different gaps. If you have Medicaid or VPharm, the state of Vermont will pay for your drugs while you are in the coverage gap, though you will likely have co-pays.
The chart below shows the average costs of the standard Part D benefit in 2017, if you do not have Medicaid, VPharm, or Extra Help (LIS):
| |
2017 Cost |
Annual Deductible Maximum
paid by member |
$400 |
| Member pays 25% of the next… |
$3,300
(25% = $825) |
Initial Benefit Period Maximum
(What the member + plan spent) |
$3,700
($400+ $3,300) |
|
Donut Hole
Member pays 40% for brand name and 51% for generics for the next...
|
$3,725 |
Catastrophic Coverage
begins when total cost of prescriptions has reached... |
$7,425 |
|
Member Cost Sharing
during Catastrophic Coverage
|
About 5%
(Minimum of $3.30 for generics and $8.25 for brand name drugs) |
The costs for plans change every year in January. You should get a letter from your plan telling you about any change in your plan.
Click on the image below to see an illustrated description of the coverage gap.
