Learn About the Donut Hole: Part D Costs
Most plans have a coverage gap, which begins when the combined amount the member and plan have spent on covered drugs reaches $4,020 (for 2020), which includes the deductible and other cost-sharing, but not plan premiums. The coverage gap stage ends when the member has spent $6,350 (in 2020) in out-of-pocket expenses for the plan year. Exceptions may apply for consumers receiving a Low-Income Subsidy (also called Extra Help).
- The coverage gap is a temporary limit on what the Medicare plan will cover for drugs.
- Not every member will enter the coverage gap.
- Once a consumer reaches the coverage gap in 2020, they will pay 25% of the cost for most brand-name drugs and 25% of the cost for generic drugs.
- Consumers who get Extra Help paying Part D costs will not pay more than LIS copayments (they still enter the stage; members are just not charged the same as non-LIS members). Some plans offer additional coverage to a member in the coverage gap, but may charge a higher plan premium. Check with the plan first to see if the drugs would be covered during the gap.