In the Medicare coverage gap, who typically pays most of the drug costs?

In the Medicare coverage gap, often referred to as the "donut hole," it is typically the member who pays most of the drug costs. This period occurs after an individual has exhausted their initial coverage limit but before they reach the catastrophic coverage threshold. During this gap, beneficiaries are responsible for a larger percentage of their medication costs—this can significantly increase out-of-pocket expenses for those who require ongoing medication.

The design of this aspect of Medicare is intended to encourage more cost-effective spending on prescriptions while supporting beneficiaries through catastrophic coverage after the coverage gap. While some assistance may come from manufacturers through discounts or additional coverage provisions, the reality is that the responsibility largely shifts to the individual during this stage, leading to higher personal expenditures. Hence, the member bears the brunt of drug costs during the coverage gap.