Coverage Gap

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  • #6062 Score: 0
    Avatarbwayne
    Participant

    I am spending a lot of money on drugs and my Part D plan. What part of my spending does not counted toward my prescription drug plan’s Donut Hole?

    #6080 Score: 0
    AvatarCatMomma
    Participant

    “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, 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).

    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 Lipitor® is not on your Medicare Part D plan’s formulary, and you have not been approved for a formulary exception, the cost of your Lipitor® purchase will not count toward your Coverage Gap.

    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 ole.”

    Reference: https://q1medicare.com/q1group/MedicareAdvantagePartDQA/FAQ.php?faq=What-costs-count-toward-entering-the-Donut-Hole-or-Coverage-Gap-&faq_id=426&category_id=114

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