How do you know if you are in the Medicare donut hole?
Asked by: Lauriane Bayer | Last update: December 3, 2025Score: 4.2/5 (46 votes)
How do you know when you are in the Medicare donut hole?
In 2024, you would enter the donut hole once you and your Part D plan together spent $5,030 on covered drugs. You'd leave the donut hole when your out-of-pocket costs for covered drugs reached $8,000. As of 2025, there's no donut hole.
How to avoid the Medicare donut hole?
Discuss lower-cost drug alternatives with your healthcare professionals. Seek out discounts on medications. Choose generic drugs over brand-name drugs. Opt for in-network pharmacies only.
Can I use GoodRx if I'm in the donut hole?
Key takeaways:
You may want to consider using GoodRx instead of Medicare when Medicare doesn't cover your medication, when you won't reach your annual deductible, or when you're in the coverage gap phase (“donut hole”) of your Medicare plan.
How long do you stay in the donut hole with Medicare?
Generally, you stay in the donut hole until you pay the set limit that's determined by Medicare each year. In 2024, you enter the donut hole once you and your plan have spent $5,030 on covered drugs, and you remain in the coverage gap until your out-of-pocket costs reach $8,000.
Medicare Donut Hole Explained Simply
Will the donut hole go away in 2025 Medicare Part?
The Medicare Part D coverage gap explained. Good news for 2025: In 2025, the Medicare Part D coverage gap, also known as the “donut hole,” will be eliminated under the Inflation Reduction Act (IRA). Part D plan members will also enjoy the security of an annual maximum out-of-pocket cost for prescription drugs.
Is Medicare getting rid of the donut hole?
Yes, the plan design for Medicare Part D prescription medication benefits will eliminate the donut hole beginning January 1, 2025.
How do you beat the donut hole?
- Lower the costs of your prescription medications by choosing a Part D plan with a formulary that includes your medications.
- Shop around to see if you can find a pharmacy that offers your medications at a lower cost.
Is there any insurance that covers the donut hole for Medicare Part B?
No. There is no insurance that can help you cover costs in the donut hole. It's important to note that some Medigap or Medicare supplement plans cover deductibles, coinsurance, and copayments for Medicare Part A and Part B only.
Who pays for drugs in the donut hole?
Just like in the initial coverage period, when you entered the donut hole, you would be responsible for paying 25% of the costs of your medications.
What is the maximum out-of-pocket for Part D in 2024?
Whether you're taking only brand-name drugs or a mix of brand-name and generic drugs, most people who reach the catastrophic coverage phase in 2024 will pay between $3,300 and $3,800 in out-of-pocket costs. In 2024, Mr. Alvarez takes $200,000 in Medicare Part D covered brand-name drugs.
What happens when I hit the donut hole?
In the donut hole, a person pays for 25% of their medication costs out-of-pocket and receives discounts from drug manufacturers to cover the remaining costs. The insurance company will add up what a person has paid out-of-pocket for medications in the donut hole.
Is Eliquis covered by Medicare?
Yes. 100% of Medicare prescription drug plans cover this drug.
What kind of financial assistance does a consumer receive who qualifies for a low-income subsidy?
Medicare's Part D Low Income Subsidy (also called LIS, or "Extra Help") helps enrollees pay for their prescription drug costs. People with incomes of up to 150% of the Federal Poverty Level (FPL) are eligible for LIS/Extra Help. Learn how the LIS/Extra Help program works, who can get this benefit, and how to enroll.
Does GoodRx count towards the donut hole?
Avoid falling into the Medicare donut hole too soon
You can use your Medicare plan for your more expensive brand drugs, and use GoodRx to purchase your less expensive generic medications. The cost of drugs purchased under GoodRx will not count against your coverage limit - thus keeping you out of the donut hole longer.
What percentage of Medicare patients hit the donut hole?
Separately Thursday, America's Health Insurance Plans, a trade group representing health insurers, said health insurance plan data show that about 10 percent of Medicare drug plan beneficiaries have reached the gap so far, with approximately 3 million expected to do so this year.
What is the best way to explain the donut hole?
Medicare drug plans previously had a coverage gap (also called the "donut hole"). The donut hole was a temporary limit on what the drug plan would cover for drugs. Now all Medicare plans include a $2,000 cap on what you pay out-of-pocket for prescription drugs covered by your plan.
Can I avoid the donut hole?
While it is not possible to completely avoid the Donut Hole in Medicare Part D prescription drug coverage, beneficiaries can take steps to reduce the amount of time they spend in this coverage gap.
Why do people say not to get a Medicare Advantage plan?
Disadvantages of Medicare Advantage plans can include difficulty switching out of the plans later, restrictions on care access, limited provider networks, and limitations on extra benefits.
What is the $2000 limit for Medicare Part D?
Thanks to the Inflation Reduction Act, in 2025 annual out-of-pocket costs will be capped at $2,000 for people with Medicare Part D.
What will the Medicare donut hole be in 2024?
The Medicare Part D donut hole or coverage gap phase of coverage no longer exists as of December 31, 2024. It was the coverage phase after the initial coverage period when you owed a higher or different percentage of the cost of your drugs.
What is the point of the hole in a donut?
To fully cook the insides of the dough, the dough would have to stay in the oil for a longer time, which would lead to the outsides becoming burnt. Punching a hole in the middle of the dough, however, allows the insides and the outsides to cook evenly, creating a perfect donut.
What is the Medicare out-of-pocket maximum for 2025?
Starting in 2025, all Part D and Medicare Advantage plans will have a $2,000 annual cap on out-of-pocket prescription drug costs (this cap was previously $8,000). Once you hit this threshold, your costs for covered prescriptions will be $0 for the rest of the year.