Donut Hole and Your Prescription Drug Insurance Part D

Part D of Medicare is supplemental medical insurance for prescription drugs associated with a health insurance plan, which you must register to pay an additional fee. Unfortunately, even if you pay extra premiums, like many health plans, there may be out-of-pocket payments, deductibles, and co-payments. One of the most frequently discussed aspects is the "doughnut hole."

What is the donut hole in prescription drug insurance?

Donut Hole is the insurance gap in the Medicare Plan D prescription drug program. Here, your insurance coverage is limited. You can buy prescription drugs yourself before you reach the limit of the gap. Once you and your plan spend $3,700 to buy the insured drug; define the sum of your deductible and co-payments paid for your plan, then you will fall into a so-called donut hole or insurance gap. Compared with the $2,830 in 2010 before the health care reform, the amount in 2017 was $3,700. The amount varies from year to year.

How does donut hole work in Medicare Part D insurance?

The coverage of Part D of Medicare provides you with coverage that reaches the specified limits. Its work is divided into three phases. First, you pay 100% until you reach your plan deductible. Then, once you pay for your prescription, after deducting your policy, you pay a certain percentage of the prescription drug fee, and the medical insurance pays the rest. Once the total cost of prescription drugs reaches $3,700, you are in the gap of donut coverage. If you and your plan premium never reached $3,700, then you won't be playing a donut hole.

If you run into a donut hole, you have to pay a higher percentage of prescription drugs until you reach the maximum pocket money limit. In 2017, the prescription drug fee limit is $4,950. Once you reach this limit, you can walk out of the donut hole and enter the catastrophic coverage we explain below. But before we arrive, let's discuss the discount, how the premium works, and how much is included in the limit.

Do you continue to pay insurance premiums within the insurance coverage?

Yes, you have to pay your premium even if you reach the gap in insurance coverage. Insurance premiums should be paid throughout the insurance period. In the donut hole does not mean that you are not covered by insurance, it means that you have reached the limit in the insurance contract, and now you are required to pay until you reach the $4,950 limit. You must pay a monthly premium for the entire insurance period or insurance year. The premium you pay is not included in the out-of-pocket limit.

What is the number of doughnut holes or gaps in the gap?

According to, the following items will be included in the coverage gap:

Discount of famous drugs
The amount of the insured drug you buy from your own pocket.

For example, the cost of a drug paid for by a third party, such as a friend, family member, or charity. The following conditions are not counted:

The premium you paid
The amount of uninsured drugs you buy from your own pocket
Purchase drugs outside your coverage network without approval
The value of a free drug, such as a sample obtained free from your doctor
The cost of purchasing medicines from abroad may not be included.

Is the coverage of branded drugs and generic drugs different?

It's important to pay attention to the differences between generic and brand name prescriptions, as well as the reasons for the catastrophic coverage of out-of-pocket expenses.