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FAQs on The Donut Hole or Coverage Gap



Browse the Medicare Part D "The Donut Hole or Coverage Gap" FAQs
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Category: The Donut Hole or Coverage Gap

Back To FAQ Home . Browse All (18) FAQs in Category

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How do I know when I will reach my Medicare Part D plan's Donut Hole or Coverage Gap?
There are a few different ways to see how close you are to your Donut Hole.  Here are a few examples of how you can tell when you have reached your Medicare Part D plan's Donut Hole (or Coverage ...

What should I do now that I am in the Donut Hole or Coverage Gap? Is there any way to save money or are there programs available to help people like me pay for my prescription drugs?
Unfortunately, if you are in the coverage gap - and your Medicare Part D prescription drug plan does not provide any donut hole coverage (for instance, generic drug coverage), then there are only...

I read that my negotiated retail prescription drug costs go toward meeting my Initial Coverage Limit before reaching my Medicare Part D plan's Donut Hole, but is this the normal retail drug cost or the total cost in my Explanation of Benefits letter?
No. Your Medicare Part D plan's negotiated retail prescription drug cost can be (and usually is) different than the retail price that your pharmacy charges and that is reported in your Explanation of ...

What costs count toward entering the Donut Hole or Coverage Gap?
Only the retail cost of formulary drugs purchased with your Medicare Part D plan are counted toward your entry into the Coverage Gap or Donut Hole.So if you purchase Medication XYZ that retails f...

You say that I will enter my Medicare Part D plan's Doughnut Hole or Coverage Gap when my retail drug costs reach a certain dollar level that changes yearly. What exactly do you mean by "retail drug costs"? Is that what I spend on my pharmacy drugs?
The "retail costs" of medications that are used to calculate when you "fall" into the Coverage Gap or Doughnut Hole are the actual negotiated cost of formulary or Part D plan cover...

When does a Medicare Part D beneficiary enter and exit the doughnut hole or coverage gap? The Doughnut Hole calculators seem to provide an estimate. But how does a beneficiary really know exactly when they enter and leave the coverage gap?
Leaving the Initial Coverage Phase and Entering into the Donut Hole A Medicare Part D beneficiary enters the  Doughnut Hole, Donut Hole  or Coverage Gap when their retail medication costs...

I think that I have already spent my way through this year's Donut Hole. Is that possible?
Yes.  If you use a great number of medications or one or more expensive medications, you spend your way into, and out of the Donut Hole rather quickly.A person enters the Donut Hole or Coverage G...

Can I avoid the Doughnut Hole if I buy a 90-day supply of my medications with the lower co-payment?
No.  Since your entry into the Doughnut Hole is based on your total retail drug expense, buying more medications at one time will actually accumulate your total retail drug cost faster and speed ...

I am spending a lot of money on drugs and my Part D plan. What part of my spending does not counted toward my prescription drug plan's Donut Hole?
Only the retail cost of formulary drugs purchased with your Medicare Part D plan are counted toward your entry into the Coverage Gap or Donut Hole.There are a number of Medicare Part D plan costs or d...

If I have to pay a higher cost-sharing for my prescriptions in the Donut Hole, why don't I just stop paying my monthly Part D plan premiums?
If you do not pay your premium, you can be disenrolled from your Medicare plan and be subject to a permanent late-enrollment penalty.  So naturally, we do not recommend that you stop paying your ...

. Newest FAQs in Category


How will I know if I reach 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 ...

What costs count toward entering the Donut Hole or Coverage Gap?
Only the retail cost of formulary drugs purchased with your Medicare Part D plan are counted toward your entry into the Coverage Gap or Donut Hole.So if you purchase Medication XYZ that retails f...

Does the Donut Hole or Coverage Gap restart every year on January 1st or do we stay in the Gap from the previous year?
Yes, your Medicare Part D plan coverage, including your Donut Hole (or Doughnut Hole) or Coverage Gap begins again at the start of each new year. For example, if you were in the 2015 Coverage Gap, ...

I never knew that there was a gap in my prescription coverage. What is the Donut Hole?!
The Coverage Gap or Donut Hole is actually similar to a second deductible in an insurance policy where you are, once again responsible for your own coverage (or a portion of your own coverage due to...

I read that my negotiated retail prescription drug costs go toward meeting my Initial Coverage Limit before reaching my Medicare Part D plan's Donut Hole, but is this the normal retail drug cost or the total cost in my Explanation of Benefits letter?
No. Your Medicare Part D plan's negotiated retail prescription drug cost can be (and usually is) different than the retail price that your pharmacy charges and that is reported in your Explanation of ...

How do I know when I will reach my Medicare Part D plan's Donut Hole or Coverage Gap?
There are a few different ways to see how close you are to your Donut Hole.  Here are a few examples of how you can tell when you have reached your Medicare Part D plan's Donut Hole (or Coverage ...

What should I do now that I am in the Donut Hole or Coverage Gap? Is there any way to save money or are there programs available to help people like me pay for my prescription drugs?
Unfortunately, if you are in the coverage gap - and your Medicare Part D prescription drug plan does not provide any donut hole coverage (for instance, generic drug coverage), then there are only...

If I have to pay a higher cost-sharing for my prescriptions in the Donut Hole, why don't I just stop paying my monthly Part D plan premiums?
If you do not pay your premium, you can be disenrolled from your Medicare plan and be subject to a permanent late-enrollment penalty.  So naturally, we do not recommend that you stop paying your ...

Will you enter the Donut Hole or Coverage Gap this year?
You can determine when (or if) you will enter your Medicare Part D Donut Hole or Coverage Gap by just dividing your Medicare Part D prescription drug plan's Initial Coverage Limit by 12 months and you...

How exactly does the Coverage Gap fit into my prescription drug plan?
Your Medicare Part D plan can be divided into four possible parts or phases and you move through these parts of your prescription drug plan depending on your prescription drug spending. The In...


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