For many seniors, medications make up a large part of their annual healthcare expenses. If you have medicare advantage or are considering enrolling you may have concerns regarding the medicare donut hole. The donut hole coverage gap affects medicare beneficiaries once their annual prescription drug costs have reached a certain amount. This article will explain some of the ways you can avoid an approaching donut hole.


Why You Should Try to Avoid the Donut Hole Coverage Gap

The Donut Hole refers to a gap in coverage that Medicare Advantage members have after $4,660 has been spent on prescription medications. During this coverage gap, Medicare Advantage plans only cover 75 percent of medication costs. This leaves you paying a substantially higher amount on your prescriptions.

Special Needs Plans Avoid the Medicare Advantage Coverage Gap

The goal of a Medicare Special Needs Plan (SNP) is to make sure individuals with serious health conditions can afford the healthcare they need. Special Needs Plans offer the most Medicare Advantage drug coverage and do not have prescription drug coverage gaps , plus eligible individuals can enroll in a SNP any time of year. For more information check out our article on switching to Medicare Advantage mid-year.


Other Ways the Medicare Advantage Donut Hole Can Be Avoided

Medicare Advantage members who do not have high drug costs will avoid the Medicare Part D donut hole. By reducing your overall drug costs, you can slow an approaching donut hole or even prevent it. Here are a few tips on how you can reduce your prescription drug costs.

Ask Your Doctor About Generic Prescription Medications

Many people worry about the differences between generic and brand name prescriptions. Having a conversation with your doctor about the effectiveness of prescribed medications is very important to receive proper healthcare.

Purchasing Generic Drugs Whenever Possible Will Reduce the Annual Cost

Medicare Advantage plans cover brand name and generic prescription drugs. Using generic drugs whenever possible will save you money at the pharmacy. These savings make a huge difference. You should always ask your doctor if the prescription they have given is available in a generic form. Purchasing brand-name drugs can be very expensive adding to the $4660 annual total quickly.

Inform Your Doctor of any Medications Not Included on Your Plan’s Drug List

It is important to make sure that your doctor is somewhat familiar with your plan’s covered drug list. This list is also known as a formulary. There may come a time when your doctor prescribes something that is not in the formulary.  It is important to find a healthcare plan with drug coverage that fits your needs.

Compare Pricing at Different Pharmacies in Your Area

Shopping around at different pharmacies will help you to find the best price. Asking the pharmacist about any discounts available can also save a lot of money. Another option that has risen in popularity in recent years is using an online pharmacy. Comparing as many pharmacies as possible will save you money and help to avoid the Medicare coverage gap.

Special Needs Plans (SNPs) Offer Relief to Those with High Prescription Drug Costs


Being prescribed a medication that has no generic alternatives may qualify you for Medicare Advantage Special Needs Plan. SNPs ensure individuals with serious health conditions can afford the healthcare they need. The cost of staying on private insurance can be far too high for those with conditions requiring extensive medication. Medicare SNPs have an out-of-pocket cap and premiums are often less than typical Medicare Advantage plans.


“All SNPs must provide Part D prescription drug coverage because special needs individuals must have access to prescription drugs to manage and control their special health care needs.” – Centers for Medicare & Medicaid Services


Catastrophic Coverage Starts After a Combined $7400 Has Been Spent

Fortunately for those with high medication expenses, the Catastrophic Coverage period limits your costs. Once you and your provider have spent a combined $7400 on covered drugs in 2023 you will enter this period reducing your percentage to 5%. The Catastrophic Coverage stops at the end of the annual coverage period.

Medicare Advantage Plans Help Patients Get the Best Care Possible.

The doctors and staff at Meadowcrest Family Physicians are dedicated to offering the best care we can to our patients. We have found that our patients are able to better afford their prescription medications with Medicare Advantage. We offer resources to better help you understand the Medicare system. If you or a loved one is having difficulty with Medicare benefits, Meadowcrest Family Physicians is here to help.