My doctor prescribed a prescription drug and even with my Part D coverage, I have to pay a lot of the cost out-of-pocket. What can I do to pay less?

First, talk to your doctor about possibly using a generic drug or a “therapeutic alternative” that costs less under your plan. You can also check and see if your copays can be reduced by using a preferred pharmacy or mail order option. Many individuals are also eligible for extra help through Low Income Subsidy (LIS) programs.

You may also be able to find a plan that has a lower copay or coinsurance for the same medication. Use your Annual Enrollment Period to “shop” different plans to make sure you are still enrolled in the best plan for your current needs. Make sure to check if there are restrictions, such as requiring prior authorization before covering expensive drugs, or step therapy, which means you have to try less-expensive drugs first, if possible.

What is the Coverage Gap or “Donut Hole” in a Part D Prescription Drug Plan? 

The coverage gap or “donut hole” requires beneficiaries to pay substantially more for their drugs when they have reached a certain level of spending. While some plans offer some coverage in the donut hole, most beneficiaries who reach the gap will experience increased costs.

The coverage gap begins once you reach your Medicare Part D plan’s initial coverage limit ($3,700 in 2017) and ends when you spend a total of $4,950 in 2017. In 2017, Part D enrollees will receive a 60% discount on the total cost of their brand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will apply to getting out of the donut hole, however the additional 10% paid by your Medicare Part D plan will not count toward your TrOOP.

What can I do to minimize my out-of-pocket spending in the “donut hole”?


Up to 25% of beneficiaries fall into the donut hole annually. Even after the discounts are applied to the prices for medicines, beneficiaries still face substantial costs.

Since you may not be able to avoid the donut hole, there are some ways you may be able to reduce your out-of-pocket costs during the coverage gap. A case in point: you may wish to talk to your doctor about the medications you are currently taking to find out if there are generic or less-expensive brand-name drugs that would work just as well. You may also consider saving money by ordering your medications through mail order pharmacies.

Another way to reduce your out-of-pocket costs is to if you are eligible to participate in any federal or state discount programs. In addition, many retail stores often offer discounted medications.