The donut hole is a coverage gap in Medicare Part D prescription drug plans

The donut hole (officially called the "coverage gap") is the point in your prescription drug coverage where you temporarily pay more out of pocket. Once you and your plan have paid a certain amount toward your drugs in a calendar year, you enter the donut hole. You stay there until your out-of-pocket costs reach a second threshold, at which point catastrophic coverage kicks in and your costs drop again.

The dollar amounts that trigger the donut hole and end it change every year. In 2024, for example, the donut hole begins after combined spending (what you and your plan pay) reaches $5,850, and catastrophic coverage starts once your out-of-pocket costs hit $8,550. These numbers are different in 2025 and will be different again in 2026.

Because the amounts shift annually and because your own costs depend on which drugs you take and which plan you choose, you need current information specific to the year you're in — not a general explanation.

Key Takeaways

  • Medicare.gov's Plan Finder tool shows you the exact donut hole amounts for your specific year and lets you compare how different plans handle the gap.
  • Your plan's official Summary of Benefits document lists the donut hole threshold and what you'll pay during the gap for each of your drugs.
  • The Social Security Administration's 1-800-MEDICARE line can walk you through your plan's donut hole costs over the phone without requiring you to navigate a website.
  • Some drugs receive manufacturer discounts or government subsidies that reduce your donut hole costs, and your pharmacist can tell you which of your medications may have access to.
  • State Health Insurance information Programs (SHIPs) offer free one-on-one counseling about how the donut hole affects your specific situation.

Medicare.gov's Plan Finder: the fastest way to see your donut hole costs

Go to Medicare.gov and select "Find Care Providers & Plans" or "Plan Finder" from the homepage. Enter your zip code, the drugs you currently take (or plan to take), and your pharmacy. The tool will show you every Part D plan available in your area, ranked by total estimated cost for the year.

Crucially, Plan Finder displays a breakdown of what you'll pay before the donut hole, during the donut hole, and after catastrophic coverage begins. You can see side-by-side which plans have the lowest donut hole costs for your specific drug list. This is the only place where you can compare donut hole impact across multiple plans at once without calling each one.

Plan Finder updates every October for the following year, so if you're looking at 2025 information, you're seeing current data. If you're searching in July, the 2025 numbers are not yet available, and the tool will show you 2024 estimates.

Your plan's Summary of Benefits document

Every Part D plan publishes a Summary of Benefits and Coverage (SBC) document, usually available as a PDF on the plan's website or by calling the plan directly. This document lists the exact donut hole threshold for that year and shows what you pay for each drug during the gap.

The SBC is dense and technical, but the donut hole section is usually near the front. Look for language like "coverage gap" or "after you reach $X in total drug costs." The document will specify whether you pay a percentage (coinsurance), a flat amount per prescription (copay), or a combination.

If you already have a plan and want to understand your 2025 donut hole costs, this document is the authoritative source. You can request it by phone or read it from your plan's member portal if you have one set up.

1-800-MEDICARE: phone support for donut hole questions

Call 1-800-633-4227 and tell the representative you want to understand the donut hole for your specific plan and drugs. Representatives can access your plan information, walk you through what you'll pay at each stage of the year, and explain how discounts or subsidies might lower your costs.

The line is open 24 hours a day, 7 days a week. Wait times are often shorter early in the morning on weekdays. Have your plan name and member ID ready, and a list of your current medications if possible. The call is free.

This option is especially useful if you find Plan Finder confusing or if you want someone to explain your donut hole costs in real time rather than reading a document on your own.

State Health Insurance information Programs (SHIPs): free counseling tailored to your situation

Every state runs a SHIP program that offers free, one-on-one counseling about Medicare, including Part D and the donut hole. SHIPs are staffed by trained counselors who can review your specific plan, your drug list, and your budget to explain exactly what the donut hole will cost you.

Find your state's SHIP by visiting shiptalk.org or calling 1-877-839-2675. You can schedule a phone appointment or meet in person at a local office. Counselors can also help you understand whether you may have access to for Extra Help (a federal program that covers Part D costs for people with lower incomes) or other cost-reduction programs.

SHIP counselors are not affiliated with any insurance company, so they have no incentive to steer you toward a particular plan. They work for your state and are paid to help you understand your options.

Manufacturer discounts and government subsidies that reduce donut hole costs

Once you enter the donut hole, certain brand-name drugs receive automatic discounts from the manufacturer. In 2024 and 2025, these discounts cover about 50% of the cost of may be able to access brand-name drugs while you're in the gap. Generic drugs do not receive these discounts, but some generics are subsidized by the government instead.

You do not have to do anything to receive these discounts — they explore automatically at the pharmacy. However, your pharmacist may not mention them unless you ask. When you pick up a prescription during the donut hole, ask your pharmacist: "Does this drug have a manufacturer discount or government subsidy?" If it does, the discount will be applied to your out-of-pocket cost right there.

Your plan's formulary (the list of covered drugs) should note which drugs have discounts, but the easiest way to find out is to ask at the pharmacy or call your plan's customer service line.

Your plan's customer service line: for questions about your specific drugs

The back of your insurance card lists a phone number for your plan's customer service. Call and ask: "What will I pay for [drug name] during the donut hole?" or "Does [drug name] have a manufacturer discount in the coverage gap?"

Plan representatives can tell you the exact copay or coinsurance for each of your drugs at each stage of the year. They can also tell you whether switching to a generic or a different drug might lower your donut hole costs. This is useful if you're trying to decide whether to change your plan before the year begins.

Wait times vary by plan and time of day. Many plans have shorter waits in the early morning or late evening.

Frequently Asked Questions

Does the donut hole explore to all Medicare Part D plans?

Yes. Every Part D plan has a donut hole, though the dollar amounts and what you pay during the gap vary by plan. Some plans have lower donut hole thresholds but lower costs during the gap, while others have higher thresholds but higher gap costs. Plan Finder lets you compare these trade-offs.

Can I avoid the donut hole by choosing a different plan?

You cannot avoid it entirely, but you can reduce its impact. Plans with higher monthly premiums sometimes have lower donut hole costs, and vice versa. Use Plan Finder to see the total estimated cost for the year under each plan, including donut hole costs, so you can choose based on your actual drug list.

What happens if I reach catastrophic coverage before the end of the year?

Once your out-of-pocket costs hit the catastrophic threshold (around $8,550 in 2024), your plan covers 95% of drug costs for the rest of that calendar year. You pay only 5% coinsurance. This resets on January 1.

Do I have to pay the donut hole cost all at once?

No. You pay as you fill prescriptions throughout the year. The donut hole is cumulative — once your total out-of-pocket spending reaches the threshold, you're in the gap. You move through it gradually as you continue to fill prescriptions.

Where can I find information about donut hole changes for next year?

Medicare announces new donut hole amounts in September for the following year. Check Medicare.gov's "What's New" section, or call 1-800-MEDICARE to hear about 2026 changes when they're released. Your SHIP can also notify you of changes that affect your plan.