Dear Marci, 

I recently got onto a Part D drug plan and am concerned about the donut hole. What should I know about it?

– Lisa (Clinton, NJ) 

Dear Lisa, 

The donut hole—also called the coverage gap—can be very confusing! Here’s what you need to know:

There are four phases of Part D coverage in 2024: the deductible, initial coverage period, coverage gap (or donut hole), and catastrophic coverage. During the deductible, you are responsible for the full cost of your medications. After you spend a certain amount, set by the plan, you reach the initial coverage period, where your plan pays a portion of your drug costs, and you pay a copay or coinsurance. After your total drug costs (what you have paid and what the plan has paid) reach a certain amount ($5,030 for most plans in 2024), you then enter the donut hole. (Note: If you have Extra Help, the following doesn’t apply to you, as you won’t have a donut hole.)

Once in the donut hole, you’ll be responsible for 25% of the cost of your drugs. You may notice a difference in what you paid for your drugs during your plan’s initial coverage phase and the donut hole. For example, if your drug costs $100 and you paid your plan’s $15 copay while in the initial coverage period, you’ll begin paying $25 for the same drug once you’ve entered the donut hole.

The donut hole phase ends when you’ve reached an out-of-pocket amount of $8,000 for covered drugs. This will put you into the next phase, called catastrophic coverage, during which you’ll have no cost-sharing for your drugs for the rest of the year. Out-of-pocket costs that count toward this $8,000 limit include:

Amounts you paid during the deductible period
What you paid during the initial coverage period
Almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap
Amounts paid by others (family members, charities, and other persons on your behalf)
Amounts paid by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and the Indian Health Service
Some costs do not count towards the $8,000 limit. These include:

Monthly premiums
Any amount your plan pays toward drug costs
Non-covered drug costs
The cost of covered drugs from pharmacies outside your plan’s network
The 75% generic discount
Your plan should keep track of how much money you’ve spent out of pocket for covered drugs and your progression through coverage periods. You can find current information in your monthly statements!

I hope that helps!

-Marci

Dear Marci, 

The cost of my medications at the pharmacy has suddenly changed even though I have the same drug plan. What could have caused this?

– Juan (Los Angeles, CA) 

Dear Juan, 

Good question! Drug costs can change throughout the year depending on which phase of Part D drug coverage you’re in.

You should know that there are four different phases of Part D coverage:


Deductible Period
You’re in this period until you meet your deductible for the year. Until then, your drugs will cost the full negotiated price. Keep in mind that deductible amounts will vary by plan.
Initial Coverage Period
Once you meet your deductible, your plan will help pay for your drug costs. You’ll have a co-payment and co-insurance determined by your specific plan.
Coverage Gap (aka the Donut Hole)

When you and your plan’s payments towards drug costs have reached a predetermined limit ($5,030 for 2024), you become responsible for paying 25% of the cost of your medications.

Catastrophic Coverage

You enter this period after you reach $8,000 in out-of-pocket costs for your covered drugs. Good news for 2024: in the catastrophic coverage phase, you’ll have no cost-sharing for the remainder of the year.

Out of pocket costs that count towards this limit include your deductible; payments during the initial coverage period; almost the full cost of brand-name drugs during the coverage gap; payments made by others on your behalf (family, charities, etc.); and payments made by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and the Indian Health Service.

Costs that don’t help you reach catastrophic coverage include your premiums, plan contributions towards drug cots, the cost of non-covered drugs, the cost of covered drugs from out-of-network pharmacies, and the 75% generic discount.


A few things to keep in mind:

Your plan should track your out-of-pocket spending and include this amount in your monthly statements.

As of 2025, the out-of-pocket maximum for covered drugs will be $2,000 and there will be no coverage gap.

Your local State Health Insurance Assistance Program can help you determine if you’re eligible for programs to help lower your drug costs.


I hope that clarifies things!

-Marci

Dear Marci, 

I might need COVID-19 treatment. Will Medicare cover Paxlovid if I need it?

-Ralph (Indianapolis, IN) 

Dear Ralph, 

Yes! Good news from Medicare! It is now covering prescriptions for the oral antiviral COVID-19 treatment, Paxlovid, through the end of 2024. You can access it in a couple of different ways.

If your Part D plan participates in the Paxlovid patient assistance program, you can have your prescription filled free of cost at your pharmacy. Contact your plan to find out if it participates.

If your plan doesn’t participate, or you simply don’t have drug coverage, you can still get Paxlovid at no charge. You’ll just need to enroll in the U.S. Government Patient Assistance Program (USG PAP) operated by Pfizer.

If you are choosing a Part D plan, you can search for Paxlovid and add it as prescription drug when comparing drug plan costs on Medicare’s Plan Finder. This will allow you to choose a drug plan that automatically covers the medication.

If you decide on a drug plan that does not cover Paxlovid, you can still obtain the medication through the USG PAP mentioned above.

Stay well!

-Marci

A survey conducted by the National Academies of Sciences, Engineering, and Medicine suggests that 1 in 3 US adults over 45 feel lonely, despite our ability to reach someone with the click of a button. Social isolation can be harmful to our health, increasing the risk of heart disease, depression, and mental decline. However, people supported by meaningful human connections tend to sleep better, experience less stress, maintain healthy habits, and have a better quality of life. Fortunately, there is a lot we can do to decrease loneliness while improving our overall health.



The CDC provides some useful tips for maintaining healthy social connections and better health:

Take time to nurture your existing relationships
Create new connections by joining a club or taking a class at your local library
Invite a friend to join you for a walk, a meal, or start a new activity together
Provide support to others in whatever ways you can
Reduce or limit your social media use; call a friend instead

Dear Marci, 

I received a discharge notice from the hospital, but I need to continue medical care. I think I can appeal but I’m not sure what to do. Please help!

-Lorraine (Buffalo, NY) 

 

Dear Lorraine, 

You’re right! If you think you’re being discharged from the hospital too soon, you do have the right to file an appeal.


You should’ve gotten a notice that explains this right titled, Important Message from Medicare, when you were admitted. If you were there more than 3 days, you should receive another copy of the same notice between 4 hours and 2 days before you are to be discharged.


The Important Message from Medicare notice will have instructions for filing a fast (expedited) appeal. This appeal will be sent to the Quality Improvement Organization (QIO), a company that is contracted to evaluate discharge appeals. For a fast appeal, you must appeal by no later than midnight on the day of your scheduled discharge. Once you file the appeal, the hospital must give you a Detailed Notice of Discharge, which must explain, in specific detail, why the hospital believes that Medicare coverage for your stay is ending, and that discharge is appropriate. You can also send additional information about why you, and your care team, if appliable, believe the discharge is too soon. The QIO should call you within 24 hours with their decision.


If the QIO agrees with the hospital that Medicare coverage of your hospital stay should end, you have the right to continue to appeal to higher levels of review. If you stay in the hospital after the QIO decision agreeing with the hospital, however, you may be responsible for the full cost of your care from the date of that decision forward if you don’t win at a higher level of appeal. There are five levels of appeal, and instructions for the next steps are included in each decision. Keep in mind that at each level there is a separate time limit for when you must file the appeal and when you’ll receive a decision.


Here are a few tips to help you succeed:

Follow the appeal timelines for each level.
Take good notes throughout the process & keep original copies of all documents.
Include a letter from your doctor or other care-team member explaining why your specific circumstances require additional hospital care to support your appeal.
Contact your State Health Insurance Assistance Program (SHIP) for more guidance on your appeal.
(Later appeals processes differ for Medicare Advantage and Original Medicare. For more information about higher levels of appeal if you are in a Medicare Advantage plan, see: Medicare Advantage appeals if your care is ending – Medicare Interactive. For more information about higher levels of appeal if you have Original Medicare, see: Original Medicare appeals if your care is ending – Medicare Interactive )


Good luck!

-Marci