Shop Part D Rx Plans
Shop & Compare Part D Rx Plans – Enter your Rx & Dosage
Donut Hole 2016
Donut Hole Chart 2017 & 2016
Explanation from Medicare & You
Donut Hole - Educational Use ONLY
Donut Hole – 2016 – Educational Use ONLY
Donut Hole - Coverage Gap
View Medicare Publication on closing the donut hole 11493
Medicare Guide to Rx Coverage
Medicare Part D Rx – Be sure to click on bookmark icon
humira part d coverage
Medicare.Gov – Comparison – Humira

How does Part D Rx coverage work in the Coverage Gap – Donut Hole?

The “standard” Part D Rx coverage works like this for 20162017 Graphic, as explained in Medicare & You 10050 on Page 111.  We can help you shop and see what Part D Rx  PDP or MAPD Medicare Advantage Plans that include Part D Rx, might work best for you.

First there is a deductible of $360.

Second, you have Initial Coverage and pay $1,098 in Drug – RX costs  – 75% Drug Plan – 25% you.

Third you enter the Coverage Gap – Donut Hole
Part D will pay 42% for generic and 5% for brand name Rx,
you pay the rest. The Drug Manufacturer will give you 1/2 off for brand name Rx. (See chart ). 

Fourth, after you pay out $4,850 you enter Catastrophic Coverage and you pay only 5% or $6.60 for a brand name and $2.95 for generic. Learn More ⇒ Medicare.Gov on better benefits through 2020

Yes, this gets confusing and changes every year.  Be sure to double check by clicking the charts and publications on the right and your Evidence of Coverage to verify the information on the plan you have.

Unfortunately, you are not allowed to buy extra coverage to cover the gap or donut hole. 

However, Insurance Companies do  offer better than the minimum standard, Part D plans, than what is shown above. Click here to enter your medications and comparison shop.  When you use, which includes NATIONWIDE Quotes, we get a finder’s fee, but are not your agent. 

In CA we suggest that you use our affiliate Blue Cross  & Blue Shield websites where you can enter the Rx you take and get a print out of what your costs will be for the year. 


Resources & Links

Our Website Introduction to Medicare  Prescription Drug Plans – Part D Rx  (credible coverage),

Medicare.Gov on Part D Rx Coverage Gap

Your Guide to Rx Coverage Publication #11109  Page 15 Coverage Gap

Donut Hole Discounts  CA Healthline 2014

CA Health Advocates RX Medicare Drug Overview

How to get a formulary exception – if your Rx isn’t on the list

Check your actual policy – Evidence of Coverage for details.

If you are getting Extra Help paying Part D costs – with the LIS – Low Income Subsidy you won’t enter the coverage gap.

Call 310.519.1335 or email us if you have questions.

Technical Research Resources

Obama Care PPACA on closing the Donut Hole

The cost of the drug is the AWP (Average wholesale price). the actual drug manufacturer sets the price and when member is in donut hole they usually won’t pay full price, they pay the AWP.

Trying to get the lowest costs in and around the donut hole.  We took Humira as an example and used Medicare.Gov (be careful and be sure to double check on the actual insurance company website – also, if you don’t get coverage from a company we represent – we will NOT be your agent and cannot contact the Insurance Company on your behalf!)  Here’s a pdf of the example or click on thumbnail at left to see a screen shot.

Child Pages

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2 comments on “Donut Hole – Coverage Gap

  1. Hi Steve,

    I’m new to Medicare and take several Rx for pain, asthma and a few other conditions. I heard that Part D makes one wait 6 months to a year to get coverage for the medications to cover a pre-existing condition. So, why should I bother getting coverage?

    ***Check our new page on Pre X and Prescriptions.

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