Avoiding the Medicare Coverage Gap: Tips for People on Disability

If you're living with a disability and relying on Medicare for your healthcare needs, one of the most frustrating surprises can be the Medicare coverage gap—commonly known as the “donut hole.” This coverage gap can result in significantly higher out-of-pocket costs for your prescription drugs. But here’s the good news: with the right strategies, you can avoid or reduce the impact of this gap.

In this post, we’ll break down what the coverage gap is, how it affects people with disabilities, and what you can do to stay ahead of it.

What Is the Medicare Coverage Gap?

The Medicare coverage gap is a temporary limit on what your Medicare Part D plan will pay for prescription drugs. Here's how it works in 2025:

Deductible Phase: You pay 100% until your plan's deductible is met (up to $545, depending on your plan).

Initial Coverage: Your plan pays most of the cost. You pay a copay or coinsurance.

Coverage Gap: Once total drug costs hit $5,030, you enter the gap. You now pay up to 25% of the cost of brand-name and generic drugs.

Catastrophic Coverage: Once you and your plan have spent $8,000, you exit the gap. Medicare then pays most of the remaining costs.

For people on disability—who may require high-cost medications—this gap can be a serious burden.

Tips to Avoid or Minimize the Coverage Gap

Use Generic Drugs When Possible

Generics typically cost less and help you stay in the initial coverage phase longer. Talk to your doctor or pharmacist about equivalent generics for your medications.

Apply for Extra Help (Low-Income Subsidy)

If you’re on disability and have limited income, you might qualify for Medicare’s Extra Help program. It can drastically reduce your drug costs and even eliminate the coverage gap altogether.

Bonus: If you're receiving Supplemental Security Income (SSI), you automatically qualify.

Choose Your Medicare Part D Plan Carefully

Not all plans are created equal. Some offer better coverage during the gap. Use Medicare’s Plan Finder to compare options and check which plans cover your prescriptions most affordably.

Track Your Spending

Keep an eye on your total drug costs, not just what you’re paying out of pocket. Once you hit $5,030 in 2025, you're in the gap. Being aware helps you prepare for the transition.

Talk to Your Doctor About Lower-Cost Alternatives

Your doctor may be able to prescribe a therapeutic alternative or lower-cost dosage that stretches your coverage. Never change meds without talking to your healthcare provider first!

Consider Drug Manufacturer Assistance Programs

Some pharmaceutical companies offer discounts or assistance programs for people with disabilities or low incomes. These programs are especially helpful while in the coverage gap.

Use Mail-Order Pharmacies

Mail-order services often offer lower prices for 90-day supplies, which can reduce your long-term costs and help you manage your budget more easily.

Watch Out for Medication Waste

Only order what you need. If your prescriptions change, you don’t want to be stuck with a stockpile of unused meds that still count toward your spending.

Living with a disability comes with enough challenges—don’t let the Medicare coverage gap be one of them. By being proactive, using available assistance, and working with your healthcare team, you can keep your medication costs manageable and your health on track.

Got questions about your Medicare coverage or want help reviewing your options? Leave a comment or get in touch—we’re here to help!