Understanding the Medicare Coverage Gap

What is the Medicare Coverage Gap?

The coverage gap in Medicare Prescription Drug plans (PDP) and Medicare Advantage plans with prescription drug coverage (MA-PD plans)  is also known as the "donut hole." The coverage gap is the point where you become responsible for paying up to 86% of generic drug prescription costs and approximately 50% of brand drug prescription costs.

The coverage gap is a standard guideline set by Medicare. All PDP and MA-PD plans have a coverage gap, but some plans offer additional coverage to help get you through the coverage gap.

You reach the coverage gap after your total yearly drug costs (paid by you and your plan) have reached $2,930. At that point, you become responsible for paying 86% of your generic prescription costs and a discounted price for your brand prescription costs of approximately 50% until you have paid $4,700 in yearly out-of-pocket costs (unless your plan offers additional coverage during the gap), as this chart below explains. Depending on how many prescription medicines you use a year, you may not reach the coverage gap.

How Medicare Part D Works
1		Deductible & annual premiums (if applicable)
2		Percentages you and your plan pay before your total drug costs reach $2,930.
3		What you pay for generic drugs after your total yearly drug costs have reached $2,930 and until your yearly out-of-pocket costs reach $4,700 (called the Coverage Gap). During this phase, you'll pay a discounted price of approximately 50% for brand-name drugs.
4		Only if your yearly out-of-pocket drug costs exceed $4,700.
	Your out-of-pocket costs
	Plan's contribution to costs

More Questions about the Coverage Gap

How can I avoid reaching the coverage gap?

Using lower cost drugs is the easiest way to avoid reaching the coverage gap. Our MA-PD plans offer low copays for generic drugs and select brand drugs. By using lower cost drugs or covered formulary generics, you won't reach the coverage gap as quickly, and in some cases, not at all. Check with your doctor or pharmacist about using lower cost drugs.

My medicine is not available in a generic version. Is there anything else I can do?

Some brand-name drugs cost less than others. If your drug is not on your plan's drug formulary, you may pay more for it. We’re happy to give you a list of similar drugs on our formulary that will be less expensive if available. Then, ask your doctor if the similar drug is safe and effective for you and if he or she will prescribe it.

You may be able to get Extra Help to pay for your prescription drug premiums and costs.

Get more information and see if you can qualify for Extra Help.