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 79% of generic drug prescription costs and approximately 47.5% of brand-name 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 $2,970 not including premium payments. At that point, you become responsible for paying 79% of your generic prescription costs and a discounted price for your brand-name prescription costs of approximately 47.5% until you have paid $4,750 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 the Coverage Gap Works |
| 1 |
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Deductible & annual premiums (if applicable). |
| 2 |
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Percentages you and your plan pay before your total drug costs reach $2,970. |
| 3 |
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What you pay for generic drugs after your total yearly drug costs have reached $2,970 and until your yearly out-of-pocket costs reach $4,750 (called the Coverage Gap). During this phase, you'll pay a discounted price of approximately 47.5% for brand-name drugs. |
| 4 |
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Only if your yearly out-of-pocket drug costs exceed $4,750. |
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 Your out-of-pocket costs |
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 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-name 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.