Coverage Gap (Donut Hole)

Topics:

Understand Coverage

Will you reach the Donut Hole in 2024?

Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. 

In 2024, once your total drug costs (what you and the plan have paid) reach $5,030; you will pay no more than 25% for brand name drugs and 25% for generic drugs. When you have spent $8,000 out-of-pocket (that includes what you pay plus the discount paid by the drug manufacturer for brand name drugs), you will reach catastrophic coverage and won’t have to pay a copayment or coinsurance for covered Part D drugs for the rest of the calendar year.

How can you save on your Medicare drug costs?

  1. Review your current plan and do a comparison every year. SHIIP-SMP can help.
  2. Explore Part D Extra Help.
    • Call SHIIP–SMP at 1-800-351-4664 (TTY: 1-800-735-2942) to see if you qualify for extra help paying for your prescription drug plan costs.
  3. Switch to generic or less expensive brand-name drugs.
    • Contact your doctor to see if you can change to a generic. This could reduce your co-payments and help maximize savings.
    • You may be able to lower your costs if your doctor will prescribe double your dosage, (e.g. 20mg instead of 10mg), and you can cut the tablet in half. You will only need to purchase 15 pills a month instead of 30. It is very important to check with your doctor as this cannot be done with all medications.
    • Check with your Part D plan to see if you could save money using mail-order.
    • Ask your doctor about free samples.
  4. Look into Patient Assistance Programs.
    • Many of the major drug companies offer assistance programs. You can find out if assistance is available for the drugs you take by calling your local SHIIP-SMP site. Call 1-800-351-4664 (TTY 1-800-735-2942) to find the SHIIP-SMP site nearest you.