The Coverage Gap or Donut Hole (or Doughnut Hole) has caused a considerable amount of confusion for many people when they suddenly are required to pay a higher price (or before 2011, the full price) for their prescription medications. The following brief overview is based on the 2019 Medicare Standard Benefit Plan Model. Quick OverviewHere is a quick overview of the Donut Hole or Coverage Gap.

• According to the Centers for Medicare and Medicaid Services (CMS) the Standard Medicare Part D Prescription Drug Plan, the Donut Hole phase of your Medicare Part D coverage begins when your total retail drug costs reach $3820. (In past coverage years, some Medicare Part D plans have implemented a different Initial Coverage Limit and have begun the Donut Hole phase a little earlier - perhaps at a total retail drug spending of $1800.)
  
  
• Please note, this $3820 is the total retail cost of the covered medications, not what you spend personally at the pharmacy. As a Medicare Part D beneficiary, you will pay only a portion of the $3820 and your Part D plan pays a portion. Your total retail cost of prescription medications is calculated from your Medicare Part D plan's negotiated retail drug price - and every Medicare Part D plan can have a different negotiated retail drug price. So it is possible that you may reach the Donut Hole a little earlier or later than someone else who uses the exact same prescription medications, but this other person has enrolled in a prescription drug plan from another Medicare Part D plan provider.
  
  
• As a note, in the CMS model Medicare Part D plan, a beneficiary; like yourself, pays the first $415 dollars as an initial deductible and then is responsible for paying 25% of the next $3405, for a total out of pocket medication costs (or true out-of-pocket costs -— TrOOP) of $1266.25 (excluding your monthly plan premiums).
  
  
• Again, following the CMS standard model Medicare Part D plan, when you reach the Donut Hole, your Medicare Part D plan will have paid the difference between the negotiated retail cost of all your drug purchases and your out of pocket cost or $2553.75.

• However, most people simply say that you enter the Donut Hole phase of your Medicare Part D plan at the end of your Initial Coverage phase or when your reach your Medicare Part D plan's Initial Coverage Limit (again, around $3820).
  
  
• With changes in the Medicare law, a $250 Donut Hole Rebate program was implemented in 2010. Anyone who reached the 2010 Donut Hole was automatically mailed a check for $250. Click here to read some frequently asked questions about the 2010 Donut Hole rebate.
  
  
• The 2011 Donut Hole marked the beginning of an effort at closing the Donut Hole. In 2011, anyone reaching the Donut Hole received a 50% discount on brand-name formulary drugs and a 7% discount on all generic formulary medications.
  
  
• In 2019, anyone reaching the Donut Hole will receive a 75% discount on brand-name formulary drugs and a 63% discount on all generic formulary medications. So for your brand-name drug purchases, you will pay only 25% of the retail cost, but receive 95% credit toward meeting your Donut Hole exit point or TrOOP. For generic drug purchases, you pay 37% of the retail cost and receive the same 37% credit toward TrOOP. 
  
  
• You will stay in the Donut Hole until your TrOOP (True Out-of-Pocket) costs reach $5100.
• If you still have questions about the Donut hole please contact me it would be my pleasure to assist you.

Are you considering Medicare Supplement insurance? Medicare Supplement plans, also called Medigap plans, can help pay for out-of-pocket costs for services covered by Original Medicare (Part A and B). It’s important to select a Medigap plan option that fits your health-care needs now and in the future because, depending on the timing of when you enroll, you might not be able to switch plans later.
There are 10 standardized Medigap plans available in every state (excluding Massachusetts, Minnesota, and Wisconsin, which all have their own versions). Each plan has a letter designation (Plan F, for example) and is sold by private insurance companies across the country. While the prices may vary across different insurers, the benefits of each Medigap plan are standardized across plans of the same letter. This means that coverage for Medigap Plan F, for example, will be the same regardless of the insurance provider.
Medicare Supplement Plans F, G, and N offer many of the same benefits, with a few differences, which this article will share.
Medicare Supplement Plan F Medigap Plan F is a popular choice that offers more coverage than any other Medicare Supplement plan. There is also a high-deductible Plan F that offers the same benefits as the standard Plan F, but requires you to pay a certain amount out of pocket before coverage starts.
Plan F benefits include:

• Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used up)
• Medicare Part A hospice care coinsurance or copayment
• Medicare Part A deductible
• Medicare Part B coinsurance or copayment
• Medicare Part B deductible
• Medicare Part B excess charges
• First three pints of blood
• Skilled nursing facility (SNF) care coinsurance
• Foreign travel emergency coverage (up to plan limits)

If you choose the high-deductible Plan F, you’ll need to pay for all out-of-pocket Original Medicare costs until you reach a designated amount ($2,300 in 2019), before your policy pays anything. However, because of the high deductible amount, you may have a lower monthly premium than the standard Plan F.
Because Medigap Plan F offers the most benefits, it is usually the most expensive; however, this may not always be the case, and you should shop around to find the best plan option for you.
You may be able to find other Medigap plans with lower premiums than Plan F. But if you see your doctor a lot or face high out-of-pocket costs, Plan F generally gives you the most help with Original Medicare costs.
Medicare Supplement Plan G Medigap Plan G offers all of the benefits of Plan F, with the exception of the Part B deductible. If you choose Plan G, you’ll need to pay the standard annual Medicare Part B deductible ($185 in 2019) out of pocket.
It’s worth noting that both Plan F and Plan G cover Medicare Part B excess charges, and they are the only Medicare Supplement plans to do so. Excess charges are the difference in cost between what a non-participating doctor or health-care provider charges for a medical service and the Medicare-approved amount. If you see a non-participating provider, he or she is allowed to charge up to 15% above what Medicare has approved for a covered service, which you’ll normally be responsible for paying.
Medicare Supplement Plan N Medigap Plan N covers all the same benefits as Plan F with the exceptions of the:

• Medicare Part B deductible
• Medicare Part B excess charges

You would need to pay these cost differences out of pocket. Plan N is also a little different from Plan F because although it pays for 100% of the Part B coinsurance in most cases, there are exceptions: You’ll need to pay up to $20 for certain office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.
What else do I need to know about Medigap Plan F, Plan G, and Plan N?If you’re thinking of signing up for Medigap insurance, a good time to enroll is during the Medicare Supplement Open Enrollment Period, which starts when you have Part B and are 65 or older. During this six-month period, you have a special right to join any Medigap plan offered by any insurance company in your service area with “guaranteed issue“; in other words, you can’t be turned down for health reasons or charged a higher premium if you have pre-existing conditions. After your Medigap Open Enrollment Period is over, it may be harder to enroll in a plan or switch plans if you don’t have guaranteed-issue rights. Medigap insurance companies can require medical underwriting or deny you coverage, especially if you have health problems.
Please note that a Medigap plan won’t work with a Medicare Advantage plan and can’t be used to pay for Medicare Part C costs. In most cases, you can’t be enrolled in both a Medicare Advantage plan and a Medigap plan, and it’s illegal for anyone to sell you a Medigap policy if they know you have a Medicare Advantage plan (unless you’re switching back to Original Medicare coverage). Also, Medigap plans don’t include prescription drug coverage, and if you’d like prescription drug benefits in addition to your Original Medicare coverage, you’ll need to enroll in a stand-alone Medicare Prescription Drug Plan.
If you’d like to find a Medigap plan option to supplement your Original Medicare coverage, or if you have questions about other Medicare plan options, you can:

• Feel free to set up a phone appointment or have me email you more information; the links for requesting those are below.
• Click the Compare Plans or Find Plans buttons on this page.
• Learn more about me in my profile below; just click the “View profile” link below.
• The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.
• Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.