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Medicare Part D Donut Hole (Coverage Gap)

Summary: The Medicare Part D donut hole coverage phase implements a temporary limit to how much your Part D plan will pay for covered drugs. During this time, you are responsible for 25% of the retail cost of your medications.  Estimated Read Time: 6 min

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  1. What is the Donut Hole in Medicare?
  2. How Does the Medicare Donut Hole Work?
  3. Can I Avoid the Medicare Donut Hole?
  4. Is the Donut Hole Going Away?
  5. Do Medicare Advantage Plans Cover the Donut Hole?
  6. Get Help Navigating the Donut Hole

Understanding how your out-of-pocket costs are determined when using Medicare Part D benefits is important.

The Medicare Part D coverage phases can make it challenging to understand exactly how much you will pay for your covered medications each time you go to the pharmacy.

The donut hole, or coverage gap, in Medicare Part D prescription drug plans, can significantly impact how much you spend out of pocket each month.

Below, we explain the donut hole phase and how you, as a beneficiary, can prepare.

What is the Donut Hole in Medicare?

The donut hole is a coverage phase of Medicare Part D plans. During this coverage phase, you have a temporary limit on how much your Medicare Part D plan will pay for your covered drugs.

Not all enrollees will enter the donut hole. However, those who do can see an increase in their out-of-pocket spending at the pharmacy during this phase.

To enter the donut hole, you must spend a predetermined amount on your drugs for the year. Once you meet this limit, you will enter into the donut hole.

In 2024, the threshold to enter the donut hole phase on all Medicare Part D plans is $5,030. However, this amount can change each year.

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Remember, individuals who receive Extra Help paying their Medicare Part D costs will not enter the donut hole phase.

In 2024, the coverage gap discount is 75%. Therefore, the beneficiary is responsible for 25% of drug costs in the donut hole.

Medicare Donut Hole Chart

The Medicare Donut Hole 2024

How Does the Medicare Donut Hole Work?

Medicare prescription drug coverage consists of multiple phases. The first phase starts on your prescription drug plan’s effective date – often January 1.

This primary phase involves reaching your deductible – up to $545 in 2024. You are responsible for paying 100% of this cost.

After meeting the deductible, you enter the initial coverage phase. During this phase, you are only responsible for copayments.

After the cost of drugs reaches $5,030 for 2024, you fall into the donut hole.

While in the donut hole, you will be responsible for covering 25% of the cost for generic and brand-name medications until the total cost of your drugs reaches $8,000.

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The final phase, catastrophic coverage, kicks in when you leave the gap.

In 2024, the catastrophic coverage phase has been phased out by Medicare Part D. Thus, once you have met the $8,000 spending limit in the donut hole, you are no longer responsible for out-of-pocket costs at the pharmacy.

Thus, once you meet the donut hole threshold, you will no longer be required to pay coinsurance for your drugs for the rest of the calendar year.  The monthly statements you obtain from your plan provider should show your current status regarding the donut hole and how much you have paid toward the maximum out-of-pocket limit.

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Can I Avoid the Medicare Donut Hole?

There are several ways beneficiaries can go about avoiding the donut hole.

However, in some cases, entering the donut hole is inevitable based on the drugs you are prescribed.

Brand-Name vs Generic Medications

If you have high-tier brand-name medications, you are more likely to fall into the donut hole than someone who takes more affordable generic medications.

To avoid the donut hole, you can ask your doctor for generic versions of any brand-name medications you are being prescribed. In most cases, the generic versions provide the same results as the brand-name medications for a fraction of the cost. However, this may not work in every situation. Ultimately, your doctor is the best determining factor in which medications are suitable for your situation. However, if a generic is available, that will help you avoid the donut hole in the future.

Compare Part D Plans Each Year

Another tip to avoid the donut hole is to compare your Medicare Part D drug plan each year during the Annual Enrollment Period. Drug plan formularies are constantly changing year over year. Thus, the plan that best suits your needs this year may not be the right plan for you next year. If a more suitable plan has become available in your area, it is important to change your coverage to minimize your out-of-pocket spending.

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Compare your Pharmacies

It is also important to compare pharmacies. Each drug plan has preferred pharmacies that offer the lowest cost of medications. If you are going to a pharmacy that is out of your plans network or is not preferred by your plan, you could be paying higher prices for your drugs without knowing.

Extra Help

Lastly, if your financial situation allows, enrollees who benefit from Extra Help will not fall into the donut hole. Starting in 2024, Extra Help will cover the costs of your medications and allow you to not have to worry about paying for your medications for all enrollees who qualify for Extra Help.

Unfortunately, these tips may not work for everyone. It is important to review and understand the benefits of your plan to help best avoid the donut hole coverage phase.

Is the Donut Hole Going Away?

2024 will be the last year Medicare Part D enrollees have to go through the donut hole coverage phase.

Due to the Inflation Reduction Act, starting in 2025, all Medicare Part D plans will have a $2,000 maximum out-of-pocket limit. Thus, taking away the need for the donut hole phase.

Once you meet the $2,000 limit is 2025, you will not be responsible for paying out-of-pocket costs at the pharmacy.

Do Medicare Advantage Plans Cover the Donut Hole?

Medicare Part C plans often include prescription drug benefits. These plans work similarly to standard Medicare Part D plans and follow the same coverage phases.

Thus, Medicare Advantage Prescription Drug Plans are still susceptible to the donut hole coverage gap.

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Get Help Navigating the Donut Hole

The donut hole can be a confusing phase in your Medicare Part D coverage. Luckily, we are here to help. As a trusted Medicare resource center, MedicareFAQ is dedicated to helping our clients understand their benefits and finding plans suitable for their needs.

To get started with one of our licensed agents today, call the number above or complete our online rate form. We compare plans from top carriers in your area to ensure you are covered!

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Costs in the Coverage Gap, Medicare. Accessed April 2022.
    https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverage-gap
  2. How to avoid the Medicare Part D Donut Hole, NCOA. Accessed April 2022.
    https://www.ncoa.org/article/how-to-avoid-the-medicare-part-d-donut-hole
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare educator serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

2 thoughts on "Medicare Part D Donut Hole (Coverage Gap)"

  1. Are Medicare telephonic agents required to explain the 4 stages and what they’ll pay in each stage based on their current medications?

    1. Hi DJ! If your current medications will reach the donut hole, only then is the agent required to explain how the four stages work.

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