Non-formulary medications, over-the-counter (OTC) drugs, and medications excluded from the Medicare Part D program by law, do not qualify for a Donut Hole discount and your non-formulary drug purchases do not count toward your total out-of-pocket drug spending (TrOOP) limit ($8,000 in 2024) – the amount you need to spend before exiting the Donut Hole.
In fact, even so-called "Bonus" or "Supplemental" drugs that are covered by your Medicare Part D plan, but excluded from the Medicare Part D program (such as ED drugs, most vitamins, and cough or cold medicine) do not receive the Donut Hole discount and are not counted toward your TrOOP.
Remember, if you are using a non-formulary Medicare Part D medication, you can ask your plan to grant a Formulary Exception -- a type of Coverage Determination so that your drug is covered by your Medicare plan and therefore is considered a formulary medication and counts toward TrOOP and receives the Donut Hole discount.
If your Medicare Part D plan denies your Formulary Exception request, you have the right to appeal your plan’s decision through several levels of review. For more information, you can click here to read about Formulary Exceptions.
Important Update: 2024 is the last year for the Coverage Gap or Donut Hole.
Starting in 2025, the Inflation Reduction Act (IRA) eliminates the Coverage Gap (Donut Hole). In 2025 and beyond, Medicare Part D beneficiaries will stay in the Initial Coverage phase until their out-of-pocket spending for Part D formulary drugs (TrOOP) reaches the maximum out-of-pocket spending limit for Part D formulary drugs (RxMOOP) - which is set at $2,000 for 2025. After reaching RxMOOP, Medicare Part D beneficiaries will enter Catastrophic Coverage and have a $0 copay (no additional costs) for all formulary Medicare Part D drugs through the remainder of the year.
2025 Medicare Part D coverage
