his article is part of an ongoing series of informative Medicare guest posts written by MedicareFAQ. – 

If you’re caring for someone who expects to wait on enrolling in Medicare until 2020, this is great news. Changes to this gap period will go into effect on January 1, 2020.

Keep in mind not all beneficiaries enrolled in a Part D plan will be faced with the Donut hole phase. As a caregiver, it’s important to find out whether the Medicare beneficiary you’re caring for could face the donut hole.

Every caregiver needs all the information about their patients’ health-care coverage. If a patient is new to Medicare, they’ll have different enrollment eligibility than someone receiving Medicare for a while.

Caregivers should notice big changes happening in Medicare 2019. This change in coverage could affect the person you’re taking care of.

Here’s what you need to know about the coverage gap ending in Medicare. The Medicare Part D coverage gap is commonly referred to as the Medicare donut hole.

Medicare Part D Donut Hole: How it Works  

The coverage gap starts once the beneficiary and their plan has spent $3,750 on drugs covered. Please note that this dollar amount is subject to change annually.

Therefore, those who currently receive extra help with their costs of Part D, this coverage gap won’t apply. Also, those that do fall into this donut hole phase, the next phase is known as the ‘Catastrophic Coverage Phase’

Medicare Donut Hole and Brand-Name Prescriptions 

In 2019, the coverage gap price is no more than 25% of the cost of brand-name drugs. Although, the savings may be higher in the coverage gap under certain plans.

Manufacturers cover 50 percent of brand name prescriptions.  

This year, 2019, the donut hole will no longer be an option for brand-name prescriptions. Under the new Bipartisan Budget Act, the Medicare donut hole will only affect generic medications.

Medicare Donut Hole and Generic Drugs  

Brand-name drugs, like most things, are replicas or copies of the original version. Generic drugs are alternatives to brand-name prescriptions.

The price your beneficiary is responsible to pay for generic drugs will be the only amount applied towards getting out of the coverage gap.

As of 2019, 63% of generic drugs will be covered; this percentage has increased since 2018.

This means extra savings for Medicare beneficiaries that already have a Medicare drug plan. Additional discounts are available once the plan’s coverage has been applied to the price of the medication.

How to Leave the Coverage Gap 

Any out-of-pocket costs paid in the coverage gap phase will be applied towards to Medicare Coverage Gap. This includes the annual deductible, coinsurance, as well as copayments you make on your drugs.

Also, any manufacturer’s discount is applied on brand-name drugs in the coverage gap. This means you can enter the catastrophic coverage phase sooner.

What is NOT Applied Towards the Medicare Coverage Gap?  

The costs of your Part D premium, any fees for pharmacy dispensing or out-of-pocket costs for drugs not included on a formulary won’t be applied towards the Coverage Gap.

What Qualifies for a Medicare Coverage Gap Discount?  

Caregivers should contact their patient’s Part D plan, to ensure the prescription records are updated and correct if the discount is not found in the Explanation of Benefits (EOB).

Insurance cards have contact information; therefore, if a drug plan disagrees with a discount, you can file an appeal.

After the Coverage Gap  

Then, the beneficiary will enter the next phase. Also starting 2019, beneficiaries’ out-of-pocket costs in the donut hole will decrease.

Insurance companies are taking on a higher percentage of drug costs, reducing the out-of-pocket cost requirement, although, the coverage gap will still exist.

Pharmaceutical companies will be responsible to cover more of the cost for prescribed drugs, however, this will leave fewer patients choosing the price of medications over the quality.

The Catastrophic Coverage Phase ensures your patient will only have to pay a small copayment or coinsurance price for covered drugs for the rest of the year.

During this phase, prescription drugs will be covered up to 95 percent.

Medicare’s Donut Hole Closing in 2019  

Originally, this gap in Part D coverage was designed to motivate beneficiaries to participate in keeping the costs of prescription drugs low.

When a beneficiary has a coverage gap, they’re more likely to ask for generic drugs whenever they can to save money. Doing this keeps the costs low for both Medicare beneficiaries and the federal government.

For the people who have illnesses that require brand-name medications, Part D coverage gap has often caused them issues.

The prescription drug market constantly has newer and “better” medications available; some work so well, that the options for alternatives simply aren’t a good option.

When some people can’t afford their medications during the gap, they simply don’t take them. This factor could potentially raise the costs for Medicare later-on for example if a patient ultimately becomes ill from not taking their medication. In this case, the patient will need more health care, more medicines and the medical costs go up.

The coverage gap has helped many Medicare beneficiaries see the plus-side in using generic drugs. On the other hand, a certain percentage of beneficiaries don’t have a choice.

The 2019 shift in the coverage gap, will be a great relief to beneficiaries that are limited to certain brand-name drugs.

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