Affording Medications in the Medicare “Donut Hole”

Betty Chaffee/ November 2, 2018/ Medication Management, Medication Therapy Management/ 1 comments

For those new to Medicare’s Prescription Drug (Part D) Plans, the “Donut Hole” is the common term for what is officially known as the “coverage gap”. Many Medicare Part D plans have a coverage gap, though not all do. Here’s how it works: Once the combined prescription costs to the insurer and the beneficiary reach $3,750 for calendar year 2018, the beneficiary will experience a gap in prescription drug coverage. The coverage gap will last until the beneficiary has reach an out-of-pocket expenditure of $5,000 for prescription drugs. During the coverage gap, the beneficiary must cover 35% of the cost of brand-name drugs, and 44% of the cost of generic drugs. If out-of-pocket drug expenses exceed $5,000 before the end of the calendar year, the beneficiary enters  the “catastrophic coverage” period during which he or she will pay no more than 5% of drug costs through December 31.

Who is affected by the Coverage Gap?

Not everyone who has a Part D plan will enter the coverage gap. Those who take a larger number of prescription medications or take very expensive medications are at higher risk of falling into the “hole”. And when it happens, it tends to be at this time of year — October, November, December — though under some circumstances people experience the gap much earlier. Some find their way out of the gap into catastrophic coverage before the end of the year, but many don’t. The end result is that for some, continuing to purchase much-needed medicine can be nearly, or even literally, impossible. It’s important to ensure that chronic medical problems don’t go untreated (or inadequately treated) during this critical period.

Finding affordable alternatives

There are many medications that can cause financial problems during the coverage gap.  Among the most frequently-encountered are medications for two common health concerns: insulin for diabetes and inhalers for lung diseases like asthma and COPD. Both can be expensive enough during the regular coverage period, and the cost can skyrocket during the coverage gap. For some people though, effective, safe, and affordable alternatives can be found.


While some insulin products can only be sold with a prescription, there are others that are non-prescription. Many pharmacies sell non-prescription insulins at an affordable price, and in many situations, with advice from a pharmacist, they can be substituted safely for the more expensive prescription-only insulins. When prescription insulin has become unaffordable, pharmacists can often help their customers to choose a safe and effective initial dose of the non-prescription insulin, and then help to monitor progress and adjust doses as required. Switching to a non-prescription alternative may result in the need for more insulin doses each day, but because it usually only lasts during the coverage gap many people find this it to be a good option.


Many people who use inhalers for health problems such as asthma and COPD have problems with the cost of these medications year-round. But things can get much worse if the coverage gap is reached, and these necessary medications can become unaffordable for some. In some situations, though, there may be affordable alternatives that can bridge the coverage gap. For example, some inhaled medications can be given by a nebulizer — a machine that turns liquid medication into an aerosol that’s inhaled gradually over the course of a few minutes. Those who have Medicare Part B coverage may be able to obtain a nebulizer and the necessary medications at an affordable cost. The nebulized medications may need to be administered more often, and the machines are not portable, but in many cases the disadvantages are outweighed by the affordability during the coverage gap period.

Planning ahead for the coverage gap

Each month, Medicare Part D providers are required to send an update that explains how much the beneficiary has paid in out-of-pocket costs and how much the Part D Provider has paid in drug costs. It also shows what stage of coverage the beneficiary is in (initial coverage, coverage gap, or catastrophic coverage) and how much more can be spent before reaching the next stage of coverage. Looking carefully at these statements each month can help in planning ahead.

Regular conversations with a pharmacist who specializes in Medication Management is one of the best ways to plan ahead for the coverage gap. Make an appointment each year for a complete medication review to estimate projected costs, look for less expensive alternatives where possible, and ensure that all the medications on the list are necessary for optimal health. In some cases a pharmacist can even justify to the insurer that a particular medication should be in a different tier, making it more affordable, because of its importance in a person’s treatment plan.

Because of provisions in the Affordable Care Act, the coverage gap will become less painful in 2019. Instead of paying 35% of the cost of brand-name drugs, beneficiaries will pay 25% of the cost, so the bite won’t be as big. But even then, planning ahead will help things go more smoothly for those who have high medication costs.

Don’t delay — get help from a pharmacist!

Of course, this time of year is a bit late for planning “ahead” for many folks. If you, or someone you know, has found medications unaffordable because of the Medicare Part D coverage gap, talk about it with a pharmacist who can help you look for affordable alternatives. Contact us at BetterMyMeds for more information!




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About Betty Chaffee

Betty Chaffee, PharmD, is owner and sole proprietor of BetterMyMeds, a Medication Management service devoted to helping people get the maximum benefit from their medications.

1 Comment

  1. Great information as always, Betty! Thanks for sharing!

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