Understanding the phases of prescription drug coverage can, at times, be overwhelming. We hope that by breaking these stages down, our team can assist you and your patients anticipate any big waves you might encounter throughout the year. Things can get pretty bumpy for patients stuck in the donut hole!
Phase 1: Pre-Deductible Phase: Initial Annual Deductible of $360 (at most)
In this phase, your patient is paying 100% of the full cost of the drug until they reach the deductible.
Tip: Some plans do not have a deductible, and other plans might offer pre-deductible coverage on tier 1 and tier 2 generics.
Phase 2: Initial Coverage: Threshold $3,310
During the initial coverage period, your patient will be paying 25% of the full cost of their prescription drugs, and the plan is paying 75% of the full cost. This occurs until the patient's total cost drugs reach $3,310.
Phase 3: Donut Hole/Gap Coverage: Threshold $4,850
Your patient will hit the dreaded donut hole when their total drug costs (including what is paid by their plan) reach $3,310. In this phase, the patient is paying 45% of the full cost of their brand named drugs, and 58% of the full cost of their generics.
Phase 4: Catastrophic Coverage
If your patient happens to breach the $4,850 threshold of the donut hole, they will break into catastrophic coverage. During this phase, they will only be paying $2.95 for generics and $7.40 – or 5% of the full cost of their prescription drugs. (Whichever is more) This phase of coverage lasts through the end of the year.
With this knowledge, you have the power to inform your patients of their total out of pocket costs for each month of the year. This information will help them to navigate through twelve months of estimated copays, monthly premiums, and the dreaded rise of costs during the donut hole.
Check out our visual breakdown of costs. You can download and print it out here!