Only the retail cost of formulary drugs purchased with your Medicare Part D plan are counted toward your entry into the Coverage Gap or Donut Hole.

For example, if you purchase Medication XYZ that retails for $1,000 and your drug plan coverage provides for a $90 co-payment for this drug, you will pay $90 - but the retail price of $1,000 will count toward meeting your Initial Coverage Limit and entering the Donut Hole.

There are a number of Medicare Part D plan costs or drug store expenses that do not count toward when you enter or when you exit the Donut Hole:

• Your monthly prescription drug plan premiums do not count toward your Coverage Gap or Donut Hole.
  
  
• The cost of any formulary medication or drug purchased without using your Medicare prescription drug plan does not count toward the Donut Hole.  For instance, if you purchase a prescription that is normally covered by your Medicare Part D plan and forget to use your Part D plan (or use a Drug Discount Card), you will pay full retail cost for the drug and the purchase will not be counted toward entering or exiting the Donut Hole.
  
  (Please note, in some instances, such as when no network pharmacy is available, you can purchase your medications at a non-network pharmacy, pay full retail price, and then ask your Medicare prescription drug plan how you can submit the claim for reimbursement.)

• The cost of any medications you purchase that are not covered by your Medicare prescription drug plan (non-formulary prescriptions) also do not count toward your Donut Hole.  So if Revlimid® is not on your Medicare Part D plan’s formulary, and you have not been approved for a formulary exception, the cost of your Revlimid® purchase will not count toward your Coverage Gap - or any other portion of your Medicare Part D plan coverage.
  
  
• The cost of any purchases of drugs excluded by the Medicare Part D program are not counted toward the Donut Hole.  For instance:
  
  
  • Over-the-counter (OTC) or non-prescription drugs;
  • Drugs used to treat cold symptoms or coughs;
  • Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations);
  • Drugs used for cosmetic purposes or hair growth;
    
  • Drugs used to treat anorexia, weight loss, or weight gain;
  • Drugs used to promote fertility;
  • Drugs used to treat sexual or erectile dysfunction
    
  
  Please note that a Medicare Part D prescription drug plan with enhanced features may provide supplemental coverage for excluded drugs as "bonus drugs" (such as Viagra), but these bonus drugs will not count toward the Coverage Gap or Donut Hole.
  

Need more help?
Still not sure how the 2024 Donut Hole or Coverage Gap fits into your Medicare prescription drug plan?  Click on the following link and send us your question: q1medicare.com/Helpdesk.php.