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Confused about the Donut Hole for Prescription drugs with Medicare.
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    Joined: May 2016
    Posts: 2
Post Date: 5/23/2016 12:24:52 AM
My question is simple.

To get into the Donut hole you "and your plan" must have spent 3310. so far in the year.
To get out of the Donut hole you "and only you" must have spent 4850 out of pocket.

How can the criteria for getting to the donut hole be based on what you and the plan have spent, while getting out of it is based on only what you have spent.??

Apples and Oranges??
    Joined: May 2016
    Posts: 2
Post Date: 5/25/2016 10:40:40 AM
Anyone? Am I over thinking this or does this seem a bit strange to you as well.?

Please your clarification is needed.
MDP Admin
    New York, New York
    Joined: May 2016
    Posts: 3
Post Date: 5/31/2016 4:04:10 PM
Yes, you are correct. There are different criteria for getting into the coverage gap (also known as the "donut hole") and for getting out of it, so it is easier to fall into the donut hole than it is to get out of it.

Please see this page for details:

The Medicare program was designed with three phases 1) where medicare plans would provide help with the cost of everyday medication initially, 2) the gap where very little is covered, limiting costs to the government and forcing consumers towards things like generic medication and 3) the catastrophic coverage phase for those consumers who have paid out a large amount out of pocket and for whom nearly all costs are covered.

You can sometimes avoid the donut hole by applying for the "Extra Help" program ( or some state programs.

And some of the Medicare drug plans offer gap coverage. Please see the "Coverage During Gap" section of our "Compare Costs and Features" pages:


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