I just started on Medicare Part D, and I'm confused about whether my new cholesterol medication counts toward my coverage gap. Can you explain?
Answered by 8 licensed agents
Figuring out how your new cholesterol medication fits into Medicare Part D’s coverage gap can be confusing—it does count toward that limit, depending on your plan’s formulary and annual drug spending. In 2025, once your total costs hit the gap, you’ll reach catastrophic coverage after $2,000 out-of-pocket, lowering your costs to zero for covered meds, and Medicare now sends a statement detailing these expenses to keep you informed. Check that statement or your plan’s formulary for a clear snapshot of your progress!
There is no coverage gap or dreaded "donut hole" starting 01.01.2025. Medicare Part D members may have high out of pocket costs initially but will be protected by a $ 2,000 annual cap on
your qualifying Rx expenses. So make sure your Part D plan covers your prescription drug list.
Each Part D plan has their own specific formulary (list of covered medications). There are also deductibles, copays, and coinsurance that factors in. It is very likely that your cholesterol medication counts towards your coverage gap but is much more complicated than yes or no. We need to know what cholesterol medication, the dosage, and plan that you are enrolled in to give a solid answer.
It depends on if your cholesterol medication is part of your Part D Prescription Drug plan formulary list. The formulary list is the list of drugs that the insurance company has agreed to make, part of their offering to the members that enroll on their plan. If the cholesterol medication is not part of the formulary, you will not have coverage and it will not count towards your yearly total spending of the $2000 limit.
Most cholesterol medications are generics and very low cost. Majority of prescription drug plans, they're either going to be a preferred generic or generic drug. Therefore, they will typically not go towards your deductible
Also plans were revised this year. The Gap has been removed
The maximum you can spend on Total drug costs for the year is $2,000
as of 2025, the Medicare Part D coverage gap is eliminated. Beginning January 1, 2025, there are now three phases of part D coverage: deductible phase, initial coverage period, and catastrophic coverage.
