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What Is the Donut Hole?

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  • Written By: Mary McMahon
  • Edited By: Kristen Osborne
  • Last Modified Date: 21 March 2014
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The slang term “donut hole” refers to a gap in coverage for prescription drugs under the Medicare Part D program in the United States. Under this plan, people who need prescription drugs initially pay for their medications out of pocket until they meet a deductible limit and Medicare Part D takes over. There is a coverage cap, however, and people who exceed it need to pay out of pocket again until they hit the threshold to qualify for catastrophic coverage. The monetary limits vary from year to year as the government adjusts the coverage, but people may have to pay several thousand dollars while trapped in the Medicare donut hole.

The inadequacy of the Medicare prescription drug coverage is an issue for health care reformers, as well as patients. It is possible to purchase plans to cover more of the donut hole, but they cost more, and people may not be able to afford the outlay of cash. In 2010, the United States government sent out checks to people falling into the donut hole to help them pay for these prescriptions, but they did not entirely compensate for out of pocket expenses.

The biggest concern with the donut hole is that because many people on Medicare are low income and may have trouble paying for prescriptions, when they hit the coverage gap, they may stop taking their medications. This could result in serious health complications, ranging from withdrawal symptoms to secondary infections.

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Some patients may attempt to ration their prescriptions before they hit the donut hole, taking the medications at larger intervals than a doctor recommends to make them last longer. This can cause problems as well, as usually prescriptions need to remain at a consistent level in the patient's body, and drug rationing can create peaks and troughs in the concentration of the drug, making it less effective.

Approaches for fixing the donut hole include changing the parameters of the coverage to eliminate this gap or make it much smaller, lowering costs on plans covering the donut hole for patients who are likely to run into this problem, and issuing larger checks to patients to help them cover their drugs. High costs of prescription drugs are another cause for concern in the United States, as patients would be less likely to max out on their insurance limit and hit the coverage gap if they had access to more affordable medications.

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