Which costs count toward entering the Donut Hole or Coverage Gap?

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Category: Entering the Donut Hole
Updated: Jun, 26 2023

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.)

Any medications that you purchase outside of the United States do not count toward the Donut Hole (for instance, if you purchase medications as you travel to Mexico or Canada).

Update September 24, 2020 - there may be a change in this policy...
Today, the U.S. Department of Health and Human Services (HHS) passed a final rule allowing states (such as Florida, Colorado, Maine, Vermont, New Hampshire and New Mexico) to import some medications from Canada at lower costs.

AARP noted that: "The final regulation will allow specific drugs to be imported, as long as they meet federal standards for safety and saving money. Though the rule goes into effect in 60 days, HHS officials could not say when actual importation plans would take effect. The plan has faced strong objections from the Canadian government and drug makers, which have said they will go to court to prevent the regulation from taking effect."

(https://www.aarp.org/politics-society/advocacy/info-2020/canada-drug-importation-ruling.html)
see the final regulation at: https://www.hhs.gov/sites/default/files/importation-final-rule.pdf)
see also: Canadian drug distributors say no to Trump import plan (12/20/2019)
https://www.reuters.com/article/us-usa-healthcare-canada/canadian-drug-distributors-say-no-to-trump-import-plan-idUSKBN1YO24O
see also: 10 FAQs on Prescription Drug Importation (03/19/2020)
https://www.kff.org/medicare/issue-brief/10-faqs-on-prescription-drug-importation/
see also: Trump Approves Final Plan to Import Drugs From Canada ‘for a Fraction of the Price’ (09/25/2020)
https://khn.org/news/trump-approves-final-plan-to-import-drugs-from-canada-for-a-fraction-of-the-price/

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.

Still not sure how the Donut Hole or Coverage Gap fits into your Medicare prescription drug plan?

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