Archive: Does the retail cost of my non-formulary medications count towards my Donut Hole?

Archive: Entering the Donut Hole · updated Aug 31, 2022

No. If a prescription medication is not covered by your Medicare Part D plan, then the purchase price for this non-formulary drug is not counted toward your Initial Coverage Limit - and is not used to determine when you reach the Donut Hole – or when you exit the Donut Hole and enter the Catastrophic Coverage phase of your Medicare prescription drug plan coverage.

You may wish to ask your Medicare plan to include these medications on your plan’s formulary by requesting a formulary exemption or coverage determination.

Bottom Line: If your formulary exception request is granted, and your non-formulary medications are covered, you will save money with your plan’s cost-sharing. And since only formulary drugs receive a discount in the Donut Hole, you would save by having the medications included under your Medicare plan, should you reach the Donut Hole or Coverage Gap.