The Donut Hole Coverage Gap Applies to Medicare Plans

The Medicare “donut hole” is also known as the Medicare Part D coverage gap. The donut hole occurs when your total drug costs reaches a given limit during an annual coverage period. The total prescription drug cost before entering the Medicare Part D donut hole in 2023 is $4,660. After $4,660 has been spent on prescription medication there will be a gap in prescription drug coverage.

The Medicare Part D Donut Hole Changed But Has Not Gone Away


Prior to 2019, reaching the coverage gap would require you to pay all for your prescription drug costs out of pocket during that period. This lack of prescription drug coverage would continue until the Catastrophic Coverage Period threshold  was met. This circumstance was known as the Medicare donut hole.


Thanks to the Affordable Care Act passed in 2010, there has been a gradual “closing” of the Medicare donut hole. But “closing of the donut hole” means that plans and pharmaceutical companies are required to cover more prescription drug costs than before. Similar to the Initial Coverage Period, entering the Medicare donut hole puts  members on the hook for 25% of their prescription costs.


If you have spent $7,400 on covered drugs in 2023, you will enter the Catastrophic Coverage Period. Fortunately, this phase offers more coverage on covered drugs than during the Medicare donut hole. During the Catastrophic Coverage Period, you will pay 5% of the cost for each covered drug, or $3.95 for generic drugs and $9.85 for brand name drugs (whichever is greater).

How to avoid the Medicare Part D Donut Hole Drug Costs

It’s important to shop around to find the best healthcare plan to suit your individual needs. Here’s some tips on how you can try to avoid the coverage gap and some ways to get financial assistance if you do enter the Medicare donut hole.


Medicare Advantage, which is Part C, offers a great way to receive affordable prescription drug benefits. The initial enrollment period for Medicare Advantage is the 6 months surrounding a person’s 65th birthday. Coverage for prescription drugs starts the month after signing up. These plans greatly reduce prescription costs even with a brand name drug.


Policies and pricing are confusing when selecting a plan with drug coverage such as Medicare Advantage. It is important to make sure you will be getting the prescription drugs you need at a price you can afford.


The Annual Enrollment Period for Medicare Advantage is October 15 – December 7. During the Annual Enrollment Period, Medicare recipients can join, switch, or leave plans. Talkwith your doctor, and compare all of the available planoptions that will help you make the best decision for your health and possibly lower your drug costs.


Many seniors worry about prescription drug coverage. The worry that their prescriptions will not be “covered drugs” or that generic drugs are the only covered drugs. Prescription drug coverage is one of the most important elements to receiving proper health care. Medicare Advantage plans provide guidance drug cost are coverage so may pay less for all of your covered drugs.

Special Needs Plans and Special Enrollment Periods Allow You to Make Changes to Your Medicare Prescription Drug Coverage

Certain life events may allow a person to make changes to their Medicare benefits and prescription drug coverage. This is considered a “Qualifying Event”. A good example of this is when we move. When someone changes residence, they become eligible for a different plan, if desired.

Special Needs Plan Members Avoid the Donut Hole

The benefit of a Special Needs Plan is that members  may avoid  the prescription drug coverage gap. This is also known as the “donut hole” which refers to a limit on covered drugs by determining how much a drug plan will pay for prescription medications after reaching a certain amount. The coverage gap begins after a member and their prescription drug plan have spent $4,660 on covered drugs for the year.

Extra Help is a Program Aimed to Help Those who Can’t Afford their Prescription Drug Coverage

Individuals with low income and limited resources may qualify to receive Medicare’s Extra Help. Extra Help is a Medicare Part D Low-Income Subsidy that reduces the cost of Medicare Advantage and prescription drug costs at the pharmacy. This program helps people get the prescription drugs they need while staying out the donut hole.

Meadowcrest Urges Patients Not to Stress About The Donut Hole.

Many seniors worry that with a prescription drug plan their prescriptions won’t be on a list of covered drugs. We have found our patients receive the best possible care affordably with Medicare Advantage. This included brand name drugs as well as other covered drugs.


Medicare Advantage prescription drug plans help seniors save money even if they enter the coverage gap. Catastrophic Coverage, Special Needs Plans and Extra Help ensure that you are able to afford prescription medications.


We at Meadowcrest Family Physicians want to make sure all our patients receive the very best care. Like many Medicare drug plans, these prescription drug plans cover brand name drugs and generics to help you lower your out-of-pocket drug costs.

Please reach out to us if you have any questions about your prescription drugs or Medicare benefits as we are happy to assist you in making the best choice to optimize your prescription drug coverage.