Medicare Part D 2011 Coverage Gap

Choosing the Correct Medicare Part D PlanThe infamous, "Doughnut Hole", or Medicare Part D Coverage Gap. What is the Medicare Part D Coverage Gap? This is a period of your Part D Coverage that you will be responsible for paying no more than 93% of the cost on your generic medications, and/or about 50% of the cost of most brand-name drugs.

A Medicare Part D member reaches this period when he/she reaches $2,840.00 collectively with their insurer. This collective amount is a total of dollars paid by the member and the plan. Once the member has reached $4,550.00 in true out of pocket costs (TrOOP), the catastrophic coverage period is entered. The member will be responsible for paying a minimal copay amount while the plan will cover the remainder on covered prescription drugs until the year's end.

Make sure that you enroll when you are eligible if you intend to ever utilize this coverage. If you do not, there are penalties that you will be subject to and they can be considerable. Anytime from three months before your 65th birthday to three months after the month of your 65th birthday is the window in which you are eligible for the Initial Enrollment.

Why is there a gap in my coverage? The Medicare Part D program is run by private insurance companies that are federally contracted and regulated to cover a certain minimum standard of benefits. Each Part D plan has a formulary, or drug list, that meets these guidelines, as required by law. However, all plans are not the same. They can vary by cost, formulary or specific drugs covered. In order to cover everyone eligible, monies must be distributed in this way, and the, "doughnut hole", is a product of this.

This is where the difficult decisions arise. Pharmacists are not able to persuade you, favor, or direct you to a particular Medicare Part D Plan. It is important to take into consideration the medicine you are currently taking, your current health, and almost predict the future. If you are a caregiver, there are often options for you to enroll in a plan on your loved one's behalf.

We will help with what we can to explain the way the program works. With the tools provided to you, proper counseling, and a some research, you will find the best plan for you or your loved one.


Jeremy KW Spiewak, Pharmacy Intern, CPhT, MA RPhT, BA Chemistry, Doctor of Pharmacy Candidate at Massachusetts College of Pharmacy and Health Sciences

Edited By:
Maryann Mackowiak, RN, CPhT, MA RPhT
Aileen Lemoine, RPh, BS Pharmacy

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Manage the Medicare Part D Coverage Gap. [online] 2011. Available through AARP Medicare Plans through UnitedHealthcare. Accessed March, 2011.

Enrollment Windows and Timing. [online] 2011. Available through AARP Medicare Plans through UnitedHealthcare. Accessed March, 2011.

Additional Resources:

Formulary Finder

Medicare and You (PDF from

Medicare Education

Medicare Plan Finder

Original Published:March 2011

Revised:January 2012