The coverage gap, often referred to as the “donut hole,” is a phase in Medicare Part D where beneficiaries may experience higher out-of-pocket costs for prescription drugs. After reaching a certain spending threshold, beneficiaries enter the coverage gap, where they are responsible for a higher percentage of their drug costs until they reach catastrophic coverage. During the coverage gap, beneficiaries typically pay a percentage of the drug’s cost (either 25% or 25% of the plan’s negotiated price) until they reach catastrophic coverage. Understanding the coverage gap is essential for Medicare beneficiaries to anticipate and manage their prescription drug expenses effectively.
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