It is possible. The Affordable Care Act limits Medicare Part D coverage for applicable drugs to only those drug manufacturers that have an agreement with the Centers for Medicare and Medicaid Services (CMS) to participate and pay discounts under the
Doughnut Hole discount program.
Because applicable drugs that are not covered under a manufacturer agreement cannot be covered under Part D, Part D plans can NOT cover any such drugs under formulary exceptions (coverage determinations), emergency first fill, or transition policies, unless Medicare has authorized this coverage.
Medicare can authorize coverage for a drug not covered under a manufacturer discount agreement if Medicare determines that the availability of the drug is essential to the health of Part D enrollees.
Important
Fact: 2024 is the last year that the Donut Hole will exist.
In 2025 one of the provisions
of the
Inflation Reduction Act (IRA) of 2022 is the elimination of
the Coverage Gap (Donut Hole). Medicare Part D beneficiaries will stay
in the
Initial Coverage phase until they reach the maximum cap on
out-of-pocket spending for Part D formulary drugs -
RxMOOP - which is set at $2,000 for 2025. After
reaching RxMOOP Medicare Part D beneficiaries will have a $0 copay for all
formulary drugs.