JL, The donut hole moves each year, and is defined by dollar levels for your total out-of-pocket cost for prescription fills through the current year. There are 4 stages of drug costs, depending on where you are wrt the donut hole. If your plan has a deductible, stage 1 applies, where you pay 100% of the plan formulary price. One the deductible is satisfied, or from $0 if no deductible to the OOP (out-of-pocket) donut hole entry point is stage 2, when you pay the formulary co-pay for your plan. Once you pass the entry point you are in the donut hole, stage 3, and your costs go up, except that during Bush2 an accelerating subsidy was passed to pay much of the donut hole premium. At the current point in time the subsidy covers more than the premium. When your total Part D OOP exceed the upper band of the donut hole you enter stage 4, where your cost will not exceep 5% of the formulary price for your plan.
Here are the boundary levels for 2019:
stage 1: deductibe stage = you pay 100%
stage 2: from deductible satisfaction to $3820 total Part D OOP
Stage 3: from total Part D OOP of $3820 to $5100
stage 4: from total Part D OOP of $5100 to whatever
Here is a practical example from my own Silverscript plan in CA:
(I am just entering stage 4, so any fills for the rest of the year will have very low copays)
T Drug Cost Copay stage Gap-Subsidy Filled date Plan paid
$96.17 $96.17 2 0 2-15-2019 $-
$140.48 $105.00 2 0 5-09-2019 $35.48
$138.19 $51.13 3 0 7-27-2019 $87.06
$114.21 $5.71 4 0 10-27-2019 $108.50
This is a generic. There was no subsidy.
Here is another example for a tier 4 brand drug:
T Drug Cost Copay stage Gap-Subsidy Filled date Plan paid
$1,851.40 $833.13 2 0 3-25-2019 $1,018.27
$1,851.40 $462.85 3 $1,295.98 7-03-2019 $92.57
$1,851.40 $165.56 3 $255.53 10-09-2019$1,430.31
Next refill will be lower cost if still in 2019.
This will probably be easier to read is copy/pasted into Excel or even Word.
