Only the retail cost of formulary drugs purchased with your Medicare Part D prescription drug plan count toward entering the Coverage Gap or Donut Hole.  Only your out-of-pocket drug spending (TrOOP) will count toward exiting the Donut Hole.

Reminder: Your total out-of-pocket spending includes what you pay and what others may spend on your behalf toward your drugs - so, at this time**, your TrOOP will include the brand-name pharmaceutical manufactures' portion of the Donut Hole Discount (70% of your brand-name drug retail costs).

Your TrOOP also includes any payments made by:

• Family members or friends,
• Qualified State Pharmacy Assistance Programs (SPAPs),
• Medicare’s Extra Help (low-income subsidy),
• Most charities (unless they’re established, run, or controlled by the person’s current or former employer or union or by a drug manufacturer’s Patient Assistance Program [PAP] operating outside Part D),
• Indian Health Service (IHS),
• AIDS Drug Assistance Programs."

(from "Understanding True Out-of-Pocket (TrOOP) Costs", CMS, November 2012)

An example of a brand-name formulary drug with a $100 retail cost and $30 copay (at a network pharmacy).

• If you have a brand-name formulary drug with a retail cost of $100 and you have a $30 copay for the drug before entering the Donut Hole, the $100 retail cost will count toward your plan's Initial Coverage Limit and entering the Donut Hole.
  
  
• The $30 copay would count toward your TrOOP (total drug spending) and exiting the Donut Hole.
  
  
• Once in the Donut Hole or Coverage Gap, you would get a brand-name Donut Hole discount of 75% (you pay $25).  So, in this example, you pay $25 of the $100 retail price.
  
  
• You get a $95 credit toward TrOOP (the $25 you spent plus the 70% discount from the brand-name drug manufacturer).

** Update May, 2018: In the document "American Patients First, The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs (May 2018)", a proposal was made to exclude the drug manufacturer's portion of the Donut Hole discount from the out-of-pocket (TrOOP) calculation. (see also: https://budget.house.gov/wp-content/uploads/2018/06/FY19_Budget-Blueprint-Final.pdf)  This proposal was NOT enacted.  If it had been enacted, you would pay $25 for a brand-name formulary drug with a retail cost of $100 and receive credit for only what you spent ($25) toward meeting your TrOOP threshold and exiting the Donut Hole - you would not receive credit for the 70% discount of the retail drug costs paid by the pharmaceutical industry toward meeting your TrOOP.

Question:  What part of my Medicare Part D drug plan costs do not count toward my Donut Hole?

A number of costs associated with your Medicare Part D plan do not count toward entering or - exiting the Donut Hole:

• Premiums.  Your monthly prescription drug plan premiums do not count toward your Coverage Gap or Donut Hole.  So, if you spend $50 per month on plan premiums, this $50 does not impact your Donut Hole.  Likewise, any late-enrollment penalty payment that you make in addition to your monthly premiums does not count toward the Donut Hole.  If you are a higher-earning Medicare beneficiary, your Medicare Part D Income Related Monthly Adjustment Amount (IRMAA) is also not counted toward entering or exiting the Donut Hole.
  
  
• Non-Part D Drug Purchases.  Any medications or drugs that are purchased "outside" of your Medicare prescription drug plan do not count toward the Donut Hole - that is, you purchase a formulary drug without showing your Medicare Part D Member ID - or when you purchase a formulary drug at a non-network pharmacy.  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.)
  
  
• Drugs Purchased Outside the U.S.  Any medication that you purchase outside of the United States does not count toward the Donut Hole.  So, if you travel to Cancun, Mexico and purchase a formulary drug, the medication costs do not count toward entering or exiting the Donut Hole.
  
  
• Non-Formulary Drugs.  Any medications not covered by your Medicare prescription drug plan (non-formulary prescriptions) also do not count toward your Donut Hole.
  
  
• Bonus Drugs.  Non-Medicare Part D drugs covered by your Medicare drug plan are not counted toward your Donut Hole.  For example, some Medicare Part D prescription drug plans with enhanced features provide supplemental coverage for excluded drugs as "bonus drugs" or "supplemental drugs", but these bonus drugs will not count toward the Coverage Gap or Donut Hole.
  
  
• Excluded Drugs.  Any purchases of drugs specifically excluded by the Medicare Part D program are not counted toward the Donut Hole.  For instance:
  
  • Drugs used to treat anorexia, weight loss, or weight gain;
  • Drugs used to promote fertility;
  • Drugs used for cosmetic purposes or hair growth;
  • Drugs used to treat cold symptoms or coughs;
  • Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations);
  • Over-the-counter (OTC) or non-prescription drugs;
  • Drugs used to treat sexual or erectile dysfunction
    

Still not sure how the Donut Hole or Coverage Gap fits into your Medicare prescription drug plan?  Click on the following link and send us your question:  q1medicare.com/Helpdesk.php.