| Thu, Aug 01, 2013 @ 09:00 AM

Medicare Part D Coverage Gap: What’s Happening Now?

Posted by Medicare Made Clear

medicare part d coverage gapThe Medicare Part D coverage gap is a period of time when you may have to pay more for your prescription drugs. It is commonly called the “donut hole.”

Up until 2011, people who “fell into the gap” had to pay 100% of the cost for their prescription drugs while in it. It didn’t happen to everybody. But if it did, prescription drugs could take a big bite out of a person’s pocketbook.

The gap is slowly closing under rules set by the Affordable Care Act of 2010. But what does that really mean?

First, a Coverage Gap Refresher

Most Medicare Part D plans have a coverage gap. It begins when you and your plan together have spent a certain amount for your prescription drugs within a calendar year. In 2013, this amount is $2,970. The coverage gap ends when you have reached the out-of-pocket spending limit for the year. The 2013 limit is $4,750.

Expenses that count toward the coverage gap amounts include:

  • Your plan deductible
  • Coinsurance and copayments you pay during the year
  • The discount you get on brand-name drugs while in the coverage gap
  • What you pay while in the coverage gap

Historically, some Medicare beneficiaries may have worried about possibly falling into the coverage gap. This worry may be going away.

Diminishing Drug Costs during the Coverage Gap

By the year 2020, the coverage gap will be closed, according to the Affordable Care Act. The closing will be gradual, though. Part D plan members will continue to pay less and less for their drugs during the gap each year until the gap closes.

The table shows the percentage of the cost of drugs that plan members will pay by year. It also shows the breakdown by type of drug—brand name or generic.


Brand Name Drug

Generic Drug


























In 2020 and thereafter, you will pay 25% of the cost for your covered drugs going forward. The percentage is the same, whether it’s for a brand-name or a generic drug. In addition, you will pay the same percentage from the time you meet your deductible (if any) until you reach the out-of-pocket spending limit for that year.

Managing the Coverage Gap

Some Medicare prescription drug plans offer coverage through copays or coinsurance in the gap. If yours does not, then you may be able to delay entering the Part D coverage gap by lowering your total drug costs. Consider these money-saving tips:

  • Switch to lower-cost or generic drugs. Ask your doctor about alternatives that may be right for you.
  • Review current medications. Work with your doctor to eliminate prescriptions that are no longer necessary.
  • Fill new prescriptions in small amounts. Commit to larger quantities when you know how you respond to the medication.
  • Go to pharmacies in your network to receive the plan’s discount price on your covered prescription drugs.
  • Use a mail service pharmacy. Prescription-drug mail services, which deliver directly to your door, may save you money on your medications.

It’s also important to monitor your monthly drug spending. If you see that you are getting close to entering coverage gap, talk to your doctor or your plan about saving on your prescriptions.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.


Donut Hole Calculator: Find out if you might fall into the donut hole.

Medicare.gov: Visit the official U.S. government site for Medicare.

Closing the Coverage Gap: Learn more about the coverage gap from Medicare’s publication on the topic.


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