For example, in 2024, the standard Initial Coverage Limit is $5,030, and you would enter into the 2023 Coverage Gap or Donut Hole if you purchase prescription drugs with a retail value of over $420 per month.
However, in 2013, the standard Initial Coverage Limit was $2,970, so if your prescription drug purchases had a retail value of over $247.50 per month, you would have entered into the 2013 Coverage Gap or Donut Hole.
As an older example, you would have entered the 2009 Donut Hole when your total retail prescription costs exceeded the 2009 Initial Coverage Limit of $2,700 in one year. This means that if your 2009 monthly retail prescription drug costs were over $225 per month, you would go into the Donut Hole some time before the end of 2009.
Here is a short list of popular brand-name medications from 2009 and their approximate retail price to give you an idea of how easy it was for the total cost of your prescriptions to reach a retail value of over $225 per month (the actual 2009 negotiated retail price for each drug would vary slightly with your Medicare Part D plan):
| Brand Names® |
Form / Strength | 2009 Retail Cost |
2020 Retail Cost |
| Actonel® | Tab 35 MG | $89 | $344 |
| Advair Diskus® | MIS 250/50 | $200 | $416 |
| Ambien® | Tab 10 MG | $154 | $606 |
| Diovan® | Tab 80 MG | $68 | $235 |
| Lipitor® | Tab 10 MG | $85 | $317 |
| Lotrel® | Cap 5-20 MG | $97 | $300 |
| Nexium® | Cap 40 MG | $162 | $302 |
| Norvasc® | Tab 10 MG | $80 | $271 |
| Plavix® | Tab 75 MG | $145 | $205 |
| Prevacid® | Cap 30 MG DR | $158 | $439 |
| Zocor® | Tab 20 MG | $147 | $256 |
| Zoloft® | Tab 100 MG | $101 | $337 |
In 2009, if you had average monthly retail drug costs of $338 for formulary drugs, you would have entered the Donut Hole in August, see: PDP-Planner.com/2009.
In 2020 your retail drug cost for formulary drugs would have to be over $503 per month for you to enter the Donut Hole in August. See PDP-Planner.com/2020.
In 2023, your average monthly retail drug costs of $583 for formulary drugs, you would have entered the Donut Hole in August. See: PDP-Planner.com/2023.
In 2024, your average monthly retail drug costs of $629 for formulary drugs, you would have entered the Donut Hole in August. See: PDP-Planner.com/2024.
Important Fact: 2024 is the last year that the Donut Hole will exist.
In 2025 one of the provisions of the Inflation Reduction Act (IRA) of 2022 is the elimination of the Coverage Gap (Donut Hole). Medicare Part D beneficiaries will stay in the Initial Coverage phase until they reach the maximum cap on out-of-pocket spending for Part D formulary drugs - RxMOOP - which is set at $2,000 for 2025. After reaching RxMOOP Medicare Part D beneficiaries will have a $0 copay for all formulary drugs.
Do you still have questions about how the Coverage Gap or Doughnut Hole works with your Medicare prescription drug plan? No problem, just click here and we will try to answer your question.