The "donut hole" in Medicare refers to a coverage gap in Medicare Part D prescription drug plans. It is a phase when beneficiaries have to pay more for their drugs. The coverage gap begins after the beneficiary and their drug plan have spent a certain amount for covered drugs, which was $4,660 in 2023 and $5,030 in 2024. Once this threshold is reached, the beneficiary enters the coverage gap, where they are responsible for a percentage of the cost of their drugs. In 2023, beneficiaries were responsible for 25% of the cost of their drugs during the coverage gap. However, its important to note that the coverage gap has been gradually closing, and the beneficiarys share of costs in the coverage gap is now limited to 25% for both brand-name and generic drugs.
To get out of the donut hole, beneficiaries can consider various strategies such as using generic drugs, taking advantage of discounts provided by their Medicare Part D plan, or exploring other assistance programs like Extra Help, Indian Health Service, AIDS drug assistance programs, charities, and State Pharmaceutical Assistance Programs (SPAPs) .
