With Doughnut Hole Gone, Medicare's Uncapped Drug Costs Still Bite

ID 60197185 © Julia Sudnitskaya | Dreamstime.com

Although federal legislation closed the doughnut hole for brand-name drugs in 2019, because Medicare has no spending limit for prescription medications in Part D, its drug benefit, some Medicare beneficiaries could owe thousands of dollars in out-of-pocket drug costs every year for a single drug.

The closure is good news, and means that  a beneficiary will only be responsible for 25% of the cost of brand-name drugs. Although the doughnut hole for brand-name drugs has closed, the beneficiary may still see a difference in cost between the initial coverage period and the doughnut hole. For example, if a drug’s total cost is $100 and the beneficiary pays the plan’s $20 copay during the initial coverage period, the beneficiary will be responsible for paying $25 (25% of $100) during the coverage gap. The doughnut hole will close for generic drugs in 2020, at which point a beneficiary will be only responsible for 25% of the cost of generic drugs.

Kaiser Health News published an excellent article, Doughnut Hole Is Gone, But Medicare’s Uncapped Drug Costs Still Bite Into Budgets, about the demise of the doughnut hole and the out-of- pocket costs beneficiaries must still face. The article focuses on the need for an annual cap on out of pocket drug spending by telling the stories of some of those who have significant out-of-pocket costs even with the elimination of the doughnut hole:

 "Legislative changes have gradually closed the doughnut hole so that, this year, beneficiaries no longer face a coverage gap. In a standard Medicare drug plan, beneficiaries pay 25 percent of the price of their brand-name drugs until they reach $5,100 in out-of-pocket costs. Once patients reach that threshold, the catastrophic portion of their coverage kicks in and their obligation drops to 5 percent. But it never disappears."

Recent proposals by the Trump administration and Sen. Ron Wyden (D-Ore.) would address the long-standing problem by imposing a spending cap. The article notes, however, that "it’s unclear whether any of these proposals will gain a foothold."

Although none of the Medicare programs have caps on spending, the article illustrates that those enrolled in original Medicare can purchase Medigap policies, which do not extend to Part D  prescription drug plans.  There's a great chart in the article that compares the existing Part D program with proposed legislation that illustrates the effect of the recent proposal to cap the annual amount.