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The Doughnut Hole (Part D Coverage Gap)

The Amount Of The Discount In The Doughnut Hole

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Because of the Affordable Care Act, the financial impact of buying drugs while in the doughnut hole is reduced each year.

The amount of the discount depends on whether the drugs are brand name, generic or relate to insulin administration. For brand name and generic drugs to be counted, the drug must be on the plan's Formulary or the plan must agree to pay for the drug.

  • For brand name drugs:  
    • During 2016 there is a 55% discount on brand name drugs when you are in the doughnut hole. 
    • This discount does not affect the amount of time it takes to get out of the doughnut hole because the pre-discount price is what counts for this purpose. 
    • There is no discount on dispensing fees which some pharmacies charge when dispensing drugs.
  • For generic drugs and for drugs which are compounded at the pharmacy: 
    • During 2016, there is a 58% discount for generic drugs and the cost of dispensing fees which some pharmacies charge when dispensing drugs.  
    • This discount does not affect the amount of time it takes to get out of the doughnut hole because the pre-discount price is what counts for this purpose. 

The amount of time  If only part of a claim is in the doughnut hole, the discount is only applied to that part of the claim.

You do not have to do anything to obtain the discounts. The discounts are applied automatically by your druggist at the time you purchase covered medications.

The discounts will get larger until 2020 when the doughnut hole will be phased out. At that point, cost sharing for both brand and generic prescription drugs will be the same during the “donut hole” as during the initial coverage period. Consequently, in 2020, individuals will pay 25 percent of drug costs, and the Part D plan will pay 75 percent.


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