Submitted by Kathy Goul, Family & Consumer Science Agent
How is it that something as wonderful as a donut hole was ever associated with Medicare?
Growing up they were a special treat that my brother and I would get to enjoy once in a blue moon. Then, in the craziness of Medicare prescription drug coverage, a donut hole became something that was no longer enjoyable. The good news is that we can once again enjoy our donut holes! Several changes in Medicare prescription drug coverage are headed our way in 2025, including the elimination of the donut hole – officially known as the “coverage gap.”
In addition to the donut hole becoming a thing of the past, two other changes in Medicare prescription drug coverage will take place next year. The biggest change is a $2,000 cap on the amount of money we will spend out-of-pocket for prescription drugs that are covered on our plan.
As you can imagine, with open enrollment starting I have been asked a lot of questions about how this all works. With the elimination of the donut hole, you will pay the cost of your prescriptions before you meet your deductible, then the cost of your prescriptions after you meet your deductible. When this total reaches $2,000, you will pay $0 for prescriptions you fill the remainder of the year.
There are some things to keep in mind to eliminate confusion. First, not everyone will reach this out-of-pocket maximum. Individuals who will approach this amount will be those on more expensive medications. If you are someone who has “hit the donut hole” in the past, chances are you may be someone impacted by this cap.
Second, keep in mind this is a cap on your out-of-pocket costs for prescription drugs covered on your plan. If you are currently taking a prescription that is not covered on your plan, the cost of that drug will not apply to the $2,000 cap. That will be an additional cost you will be responsible for. Finally, it is important to note your monthly plan premium is not included in this amount. You will still be responsible for paying your plan premium for each month of the year.
The third major change to Medicare prescription coverage this year involves the addition of a Medicare Prescription Drug Payment Plan. This payment options works with your drug coverage to help you manage your out-of-pocket costs for drugs covered by your plan by spreading them across the calendar year. Participation in this plan is voluntary. Individuals most likely to benefit from participating in this program are those who have higher drug costs earlier in the calendar year.
Each year I encourage Medicare beneficiaries to review their prescription drug coverage during open enrollment (October 15 – December 7). In addition to the major changes I have listed above, plan changes may affect your monthly premium, deductible, drug co-pays, out-of-pocket maximum (for Medicare Advantage plans), and your pharmacy, doctor or hospital choices. Knowing the options available to you will help you make the decision that is best for you in 2025.
To review your current coverage and compare plans for the coming year, individuals can visit medicare.gov and use the plan finder. This tool walks you through the steps of comparing your current plan to the plans available for next year. To use the plan finder you must create a MyMedicare.gov account.
K-State Research & Extension provides free, unbiased assistance to help with your plan comparisons through a partnership with the state Senior Health Insurance Counseling for Kansas (SHICK) program. Individuals seeking help with plan comparisons can pick up an intake form at our Paola office, located at 913 N. Pearl Street, Suite No. 1, or our Mound City office, located at 115 S. 6th Street. The intake form can also be found on our website at www.maraisdescygnes.k-state.edu. Once this form is completed and returned to the office, we will contact you to help you with your plan comparison.
Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. If you decide not to get drug coverage when you are first eligible for benefits, you will likely pay a late enrollment penalty if you join later. You will pay this penalty for as long as you have Medicare prescription drug coverage. Exceptions to this rule include if you have other credible drug coverage (such as through an employer plan), or you receive extra help with your Medicare prescription drug plan.
If you are not currently taking any prescription drugs, we encourage you to consider enrolling in the least expensive Medicare prescription drug plan. Your health needs can change throughout the year. This provides you with coverage, if needed, and helps you avoid late enrollment penalties.
For more information about open enrollment and how we can help, visit our website at www.maraisdescygnes.k-state.edu. Look for the link in our Hot Topics section for Medicare Open Enrollment. For questions by phone, please call our Paola office at 913-294-4306.
Source: Medicare.gov.