Archive: How will I know if I am in the Donut Hole portion of my Medicare prescription plan?

Review your Explanation of Benefits. Each month, your Medicare prescription drug plan will send you a printed Explanation of Benefits letter that will show you how close you are to entering the Coverage Gap or Donut Hole portion of your Medicare Part D plan.

Also notice when the price you pay for your medications changes.

Even if you do not review your Explanation of Benefits (EOB) letters, you may notice your entry into the Donut Hole because the cost of your medications has increased (it could be the cost of one medication or all of your medications at once). Remember that with the 75% Donut Hole discount, the Donut Hole may be the less or some people already paying a 25% co-insurance will not notice a change.

For example, you may have a medication that has a $371 retail cost and you are paying a $43 co-pay for the drug (as a Tier 3 formulary drug) while in your Initial Coverage Phase. However, once you reach the Donut Hole or Coverage Gap, you will receive a 75% discount on this brand-name drug and pay 25% of retail or $92.75 instead of the $43 co-pay.

You can also calculate when you will enter the Donut Hole.

You will be able to take your plan's Initial Coverage Limit (in 2024, the Initial Coverage Limit $5,030 and divide by the 12 months. If your monthly retail drug costs are over this amount (not what you spend with Part D, but the actual retail value), you will enter the Donut Hole sometime during the year.

For example, if you purchase formulary medications with a retail value of over $420 per month, you will enter the Donut Hole or Coverage Gap some time in 2024.

You can also use our online Donut Hole Calculator to visualize your Donut Hole exposure.

To help you visualize how far you are from the Coverage Gap, you can also try our Donut Hole Calculator where you enter the monthly retail value of your medications and see a chart of your costs across the Part D coverage phases. Our Donut Hole Calculator can be found at: PDP-Planner.com. (The Donut Hole discount calculations can be found at the bottom of the chart.)

For more tips, please see our FAQ "How will I know if - or when I reach my Medicare Part D plan's Donut Hole or Coverage Gap?"