The Truth About Part D “Donut Hole”

It’s no secret that the “donut hole” in Medicare Part D (prescription drug coverage) is a major concern for seniors. There are many misconceptions about how to get out of it and what the consequences are if you don’t get out of it. In this blog post, we’ll clear up some misunderstandings and provide tips on how to avoid getting stuck in the donut hole.

Are you feeling the pain of your Medicare Part D’s “donut hole”? Well, we have a solution to that. We will show you how to get out of it – and for free! It’s as easy as picking up the phone and calling us. Plus, our customer service is second-to-none. Isn’t it time you took back control?

Medicare Donut Hole

Most beneficiaries have a challenge understanding the donut hole meaning, we will break it down.

Medicare Part D has four stages. The third stage is the donut hole, which used to be a gap in coverage during a calendar year when you were paying for brand-name drugs out of pocket.

However, this only applied if you had not reached your limit on what percentage of drug costs was covered by Medicare; now that people are reaching their limits more often with high prescription prices and copays increasing all over the place, they say “The Donut Hole” because it’s no longer merely an abstract term coined from confusion or misunderstanding – there really is one!

How does the Medicare donut hole work

The Medicare donut hole is a gap in Part D plans that can save money on medication costs. Once your spending reaches the threshold for this coverage, you may find yourself paying more than before even though there are savings to be found depending on what you paid during the initial coverage stage.

Medicare’s Part D program was designed to provide coverage for the majority of your prescription drugs. However, a small percentage of people have medication costs that go well beyond average spending and enter Medicare’s coverage gap.

Congress has put in place measures to encourage beneficiaries when possible, seek generics or drug alternatives that are lower in cost, and help keep total costs as low as possible with this plan design measure.

Is the donut hole going away

It seems like it will never end, but when you hit that point where you are paying 100% of the costs for your prescriptions while in the donut hole gap, there’s hope! The government has been reducing this percentage steadily and as of 2021–no more than 25%.

How much do I pay for drugs in the donut hole

Once you and your insurance plan have spent a total of $4,130 in 2021, you will move into the Medicare donut hole. In this gap between Part A and Part B coverage for prescription drugs on an out-of-pocket basis (i.e., when beneficiaries spend more than they are entitled to overtime).

In fact, there is no financial assistance or subsidies available from Social Security Administration like before; patients must pay 25% of their drug prices while having reached that point with deep pockets!

For example, if we said once a certain medication costs $100 by 2021–both brand name as well generic!–you would be required to shell out around one-quarter of its cost ($25), which may just make it too expensive after all…

The gap is a time in which the patient pays their own out-of-pocket costs and Medicare covers no more than what it would have spent on them under original coverage.

They reach catastrophic coverage, where they will pay either 5% or a small copay (whichever is greater) of the cost for drugs with insurance picking up most of that difference after reaching $6,550 worth of medication expenses this year.

It can be difficult to make it through the donut hole that Medicare Part D leaves behind, but just a few years ago there was no prescription drug program for these beneficiaries. Many seniors are thankful for this improvement and life-saving change in their lives!

Some Part D carriers negotiate with pharmaceutical manufacturers to purchase discounted drug rates. This means you’ll pay less than if you were not enrolled in the plan, since most of these discounts are passed down to those who participate.

What does not count towards the coverage gap

When you are in the gap, your spending counts toward exiting. Your drugs will cost 25% less than retail and 70% of this discount is counted towards closing the gap for you!

The other thing to remember is that out-of-pocket costs paid by a drug plan don’t count either: 5% (and 75%) on prescriptions or dispensing fees respectively.

There are two things though which won’t help with getting back into pocket – 5%, meaning prescription prices; and 75%, representing how much pharmacists get from their fee per script.

One of the many benefits to Medicare Part D is that it does not count towards your catastrophic limit. Your plan premium and any drugs you buy which are not covered by your plans do, however.

One perk with obtaining a plan through Medicare Part D is that they don’t reach the catastrophic limit between deductibles and coinsurance amounts; only premiums for insurance coverage or pharmaceutical costs outside what’s offered in their traditional program counts as part of this threshold amount.

Who qualifies for health coverage exemption

Asking Medigap to cover the coverage gap in your drug plan is like asking a car insurance company to pay for you oil changes. They can only help with one category of expenses: Inpatient and outpatient services.

Drugs are not covered under Part D, but they fall into this other Medicare part that handles drugs specifically (Part B).

The donut hole exists because it’s actually cheaper for pharmaceutical companies if people have no access during those final stages before catastrophic coverage kicks in again at $4100/year out-of-pocket costs than if they had 100% reimbursement rates all along.

If you’re struggling to pay for healthcare or prescription drugs, then Extra Help may be able to help. The low-income subsidy waives the Medicare Part D gap and lowers your copays on prescriptions! You can apply online at Social Security’s website–it only takes about 10 minutes of time.

How can the coverage gap be avoided

The Medicare donut hole is a term to describe the coverage gap for Part D plans. When your total medication costs reach this amount in one calendar year, you enter into what has been called “the doughnut hole.”

Fortunately, there are ways of lowering these expenses through drugs’ financial assistance programs or by choosing cheaper alternatives that will still provide adequate care – and remember: always review your statements from the insurance company!

PQ Medicare Solutions is a full-service agency that not only finances and sells Medicare Supplement Plans, but also offers one of the most comprehensive sets of products in the industry.

When you buy your plan from PQ Medicare Solutions, we will help to make sure everything goes smoothly for you before coverage kicks in by providing ongoing information on how to use Plan Finder each fall (limited exclusively to our policyholders).

If you’re really concerned about drug costs during this gap period where there are no safety nets like Medicaid or family budgets can handle it alone – ask us for assistance with Part D once your Medigap has been bought through us!


It’s time to get out of the donut hole. The first step is getting a quote for your prescription drugs from Medicare Part D, and then you can decide whether or not to fill prescriptions. With an estimated $4 billion in savings on the line, there’s no reason why any senior wouldn’t want this information at their fingertips. Get started with our free quote today!