Is the 52.5% Donut Hole discount always applied automatically to my prescription purchase while in the Gap?

Yes. The Donut Hole discount is applied automatically at the point-of-purchase when you buy medications in the Coverage Gap. The 52.5% discount is applied to brand-name medications and the 21% discount is applied to generic medication purchases.

Depending on the pharmacy, your physical receipt may show the discount or you can see the discounts listed on your monthly "Explanation of Benefits" letter that you receive from your Medicare Part D prescription drug plan.

However, it is always possible that a mistake has occurred and you can check your purchase price against the normal retail cost of the medication. If the discount is not applied, you can contact your Medicare Part D plan Member Services department and ask about receiving a refund. (The toll-free number for the Member Services department is on the back of your Member ID card).

Please note that if you purchase a non-formulary medication (not covered by your Medicare prescription drug plan), you will not receive any Donut Hole discount and you will continue to pay full-retail cost for the medication as you did before reaching the Donut Hole.

In this situation, you should consider asking your Medicare Part D plan for a Formulary Exception or Coverage Determination whereby a non-formulary drug would be covered by your plan. You can click here to learn more about Formulary Exceptions.

Also, if you did not fill your prescription at one of your Medicare Part D plan’s network pharmacies, you would not have been able to use your Medicare Part D coverage and would pay full price for any medication purchases. Your Medicare Part D plan should have an online tool that shows you all of the network (and preferred network) pharmacies in your area.

To provide some help, we now have links to some of the larger Medicare plan pharmacies searches online. If you still need help finding your Medicare plan’s pharmacy search, you can click here to let us know and we will try to find the link for you.