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Many of you have heard of the dreaded Donut Hole. Some unfortunate ones have even experienced it. A few of you might be thinking about a trip to Dunkin. But here is what it’s all about…
The Donut Hole is another term for the Medicare Prescription Drug Coverage Gap. The Center for Medicare and Medicaid Services (CMS), determines the figures for the Coverage Gap on an annual basis.
For 2021, consumers enrolled in a Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug Plan can expect to have a maximum annual deductible of $445. This means that consumers may have to pay up to $445 before receiving any benefits from their plan.
Once the deductible is met, consumers are in their Initial Coverage Stage. During this stage, consumers can expect to pay their copays for their prescription medications, while the insurance plan may pay the difference. Consumers will remain in this Initial Coverage Stage until their Total Drug Costs reach $4,130. The Total Drug Costs is calculated by adding what the consumer has paid toward their deductible plus what the consumer paid in copayments plus what the insurance company has paid towards the medications.
Once the consumer reaches the $4,130 threshold, they then move to into the Coverage Gap, also known as the Donut Hole. During this time the consumer will pay 25% of the cost of their medications until their Total Out-of-Pocket costs reach $6,550. The Total Out-of-Pocket costs are calculated differently, however. The consumer’s Total Out-of-Pocket is determined by adding what the consumer has paid towards their deductible plus what the consumer has paid in copays in the Initial Coverage Stage plus what the consumer has paid while in the Donut Hole.
After a consumer reaches the $6,550 in Total Out-of-Pocket costs, they move into the Catastrophic Coverage stage. At this point, consumers will pay 5% of the cost of their medications or $3.70 for generic medications and $9.20 for brand name medication, whichever is greater.
It is important to know that if a consumer is eligible for either Medicaid or Extra Help, they are not subjected to the Donut Hole.
- Details
- Hits: 640
Many of you have heard of the dreaded Donut Hole. Some unfortunate ones have even experienced it. A few of you might be thinking about a trip to Dunkin. But here is what it’s all about…
The Donut Hole is another term for the Medicare Prescription Drug Coverage Gap. The Center for Medicare and Medicaid Services (CMS), determines the figures for the Coverage Gap on an annual basis.
For 2021, consumers enrolled in a Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug Plan can expect to have a maximum annual deductible of $445. This means that consumers may have to pay up to $445 before receiving any benefits from their plan.
Once the deductible is met, consumers are in their Initial Coverage Stage. During this stage, consumers can expect to pay their copays for their prescription medications, while the insurance plan may pay the difference. Consumers will remain in this Initial Coverage Stage until their Total Drug Costs reach $4,130. The Total Drug Costs is calculated by adding what the consumer has paid toward their deductible plus what the consumer paid in copayments plus what the insurance company has paid towards the medications.
Once the consumer reaches the $4,130 threshold, they then move to into the Coverage Gap, also known as the Donut Hole. During this time the consumer will pay 25% of the cost of their medications until their Total Out-of-Pocket costs reach $6,550. The Total Out-of-Pocket costs are calculated differently, however. The consumer’s Total Out-of-Pocket is determined by adding what the consumer has paid towards their deductible plus what the consumer has paid in copays in the Initial Coverage Stage plus what the consumer has paid while in the Donut Hole.
After a consumer reaches the $6,550 in Total Out-of-Pocket costs, they move into the Catastrophic Coverage stage. At this point, consumers will pay 5% of the cost of their medications or $3.70 for generic medications and $9.20 for brand name medication, whichever is greater.
It is important to know that if a consumer is eligible for either Medicaid or Extra Help, they are not subjected to the Donut Hole.
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Unused Medication Drop-off Locations
US DEA Locations
Arden
CVS, 324 Long Shoals Rd, Arden, NC 28704
Asheville
Asheville Discount Pharmacy, 76 Patton Ave, Asheville, NC 28801
CVS, 24 Westgate Pkwy, Asheville, NC 28806
CVS 505 Smokey Park Hwy, Asheville, NC 28806
Walgreens, 578 New Leicester Hwy, Asheville, NC 28806
Walgreens, 1835 Hendersonville RD, Asheville, NC 28803
Black Mountain
Sunshine Pharmacy, 206 E State St, Ste 1, Black Mountain, NC 28711
Healthridge Pharmacy, 3130 US Hwy 70, Black Mountain, NC 28711
Brevard
CVS, 371 Asheville Hwy, Brevard, NC 28712
Gordon Family Pharmacy/Fernhill Pharmacy, 518 S Broad St, Brevard, NC 28712
Candler
Carolina Mountain Pharmacy, 7 Pisgah Hwy, Ste 100, Candler, NC 28715
Cashiers
A to Z Drugs, 52 Cashiers Shopping Center, Cashiers, NC 28717
Cherokee
Cherokee Indian Hospital, 1 Hospital Rd, Caller Box C-268, Cherokee, NC 28719
Fletcher
CVS, 3450 Hendersonville Rd, Fletcher, NC 28732
Franklin
Smart Pharmacy, 60 Georgia Rd, Franklin, NC 28734
Hendersonville
CVS, 1605 Four Seasons Blvd, Hendersonville, NC 28792
Mills River
CVS, 128 Cross Road Dr, Mills River, NC 28759
Swannanoa
CVS, 2351 US Hwy 70, Swannanoa, NC 28778
PSA Clinic Pharmacy, 2294 US Hwy 70, Swannanoa, NC 28778
Sylva
CVS, 88 NC Hwy 107, Sylva, NC 28779
Walgreens, 36 Sunrise Park, Sylva, NC 28779
Waynesville
CVS, 773 Russ Ave, Waynesville, NC 28786
Walgreens, 590 Russ Ave, Waynesville, NC 28786
Woodfin
CVS, 471 Weaverville Rd, Woodfin, NC 28804
Weaverville
CVS, 121 Monticello Rd, Weaverville, NC 28787
Other Locations
Buncombe County Sheriff’s Office
Buncombe County Courthouse
Cherokee County Sheriff’s Office
Clay County Sheriff’s Office
Franklin Police Department
Graham County Sheriff’s Office
Haywood County Sheriff’s Office
Henderson County Sheriff’s Office
Jackson County Sheriff’s Office
Madison County Sheriff’s Office
Murphy Police Department
Swain County Sheriff’s Office
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MEDICARE – 1-800-MEDICARE (1-800-633-4227)
SOCIAL SECURITY ADMINISTRATION (1-800-772-1213)
(or locally at 1-866-562-0738, Franklin NC office)
APPLY ONLINE FOR EXTRA HELP
http://www.socialsecurity.gov/extrahelp
REPORT MEDICARE FRAUD, WASTE & ABUSE (1-800-MEDICARE)
https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx
REQUEST NEW OR CORRECT MEDICARE CARD -
from Social Security Administration (1-800-772-1213)
(or locally at 1-866-562-0738, Franklin NC office)
SENIORS-HEALTH INSURANCE INFORMATION PROGRAM (SHIIP)
(855) 408-1212
http://www.ncdoi.com/SHIIP/Default.aspx
NORTH CAROLINA DEPARTMENT OF INSURANCE
SILVER SNEAKERS (GET YOUR CARD)
https://tools.silversneakers.com/Eligibility/GetCard