Medicare’s Donut Coverage


Last May, I moved my father from Atlanta to Jacksonville. At 57 years old, my father would be the first to tell you he is not a senior. He is, however, permanently disabled from a ruptured spinal cord injury he suffered in 2007.

Since then, his life has rapidly changed, and as his power of attorney, we both have become far too familiar with the pros and cons of Medicare health insurance and the costs of prescription medications, and we have grown accustomed to being put through the “donut hole” coverage.

If you do not know what this is and are an approaching senior or a current senior citizen, then I recommend a quick Google search to get accustomed to a coverage loophole that may end up devastating you financially. states on its website that the term “donut hole” means “there’s a temporary limit on what the drug plan will cover for drugs. … In 2018, once you and your plan have spent $3,750 on covered drugs, you’re in the coverage gap.” Therefore, when you reach certain deductibles (either with your prescriptions or medications during hospital visits), your insurance will no longer pay for your prescriptions at the cost that they were being paid for at the beginning of the year.

Imagine a senior citizen who has worked the majority of his or her life, but after working 30 to 40 years, that person now becomes disabled for whatever reason. Maybe this person goes through a major surgery and the surgeon writes multiple pain prescriptions. The prescriptions for pain medications can be anything. After surgery and during the healing process, what happens if the patient starts to feel depressed? Or what if they start to become addicted to the pain medication?

For the depression, the patient now will most likely be prescribed an antidepressant. In a blink of an eye, the patient is now on pain medications and antidepressants. Your diet might also be an issue, and now diabetes may become a factor. The costs for insulin under Medicare are shocking. How does a patient only on Medicare afford this? What happens if there are setbacks, additional hospital visits or if the original surgery was unsuccessful and now one surgery turns into two or even three?

Well, this is when you are probably going to get familiarized with the “donut hole.” You will also get the spiel that if you do not like it, then you have the option of not receiving your Social Security benefits anymore and can elect to receive Medicaid.

Therefore, depending on your drug and if it is generic or a brand name, you could now be on the hook for 44 percent of what the drug costs in its entirety. The percentages may not seem as much, but imagine if the monthly prescription costs $900. If you are in the “donut hole,” you may have to pay $396 for your monthly drug.

What’s the point of this story, and why is it directed to the senior living section of the Recorder? I wanted to make readers receiving these benefits aware. We never know what may happen as we get older, and I hope everyone reading this is healthy. However, it would not hurt to call your insurance provider and make sure you know about your coverage limitations and any potential donut holes, especially if you have reached certain limits of coverage for the year. Regardless of your monthly income or need for medication, if you cannot come up with the “donut hole” funds, then you most likely will be without your medications that you might have now become dependent on taking. 


Joseph Alvarez is an associate attorney at Zisser Law, where he specializes in criminal and marital law.

The numbers used in this article are based on the experiences of the columnist.