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?

Question

Brian Moore · Accepted Answer

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!

Answered by Brian Moore on March 27, 2025

Broker Licensed in OH

Answered by Brian Moore Medicare Insurance Agent

Melonie Wood · Answer

I have a special database that I am able to put a members medication in which will give us the costs .  2025 there is no coverage gap.

Clarence &quot;Mark&quot; Christiansen · Answer

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.

Christy Jones · Answer

The coverage gap went away for 2025. There is now a $2000 max for prescriptions. As long as your cholesterol medicine is on your prescription drug plan formulary it will count towards the $2000 max. If your prescriptions were to reach/exceed $2000, your prescription
cost over $2000 would be zero dollars for the rest of the calendar year.

Mitch Anderson · Answer

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.

Answered by Mitch Anderson on March 25, 2025

Agent Licensed in MN, IA & WI

Answered by Mitch Anderson Medicare Insurance Agent

David Wiley · Answer

It does as it counts not only what you pay but counts the total negotiated cost that your insurance company pays as well.

Steven Bleicher · Answer

The Inflation Reduction Act of 2023/24 has fully eliminated the coverage gap which also used to be called “the donut hole”. Thus with that legislation, the maximum out of pocket costs in 2025 are $2,000.00 tops! This will be tracked by Medicare and includes both generic and brand name drugs, including your cholesterol meds. Your Primary doctor or cardiologist should know which Rx's are the most expensive (with higher copays at your “preferred” pharmacy) and which are more reasonably priced.

Answered by Steven Bleicher on May 24, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Timothy Brown · Answer

First let me begin by stating that yes, all prescriptions count towards your maximum out of pocket limit for 2025 which is $2,000. There coverage gap, better known as the “donut hole” has been eliminated due to the Inflation Reduction Act which began in January 2025.

Answered by Timothy Brown on June 22, 2025

Broker Licensed in PA, CT, DE & 15 other states

Answered by Timothy Brown Medicare Insurance Agent

Barbara Barnes, CMIP® · Answer

Well, first of all, in 2025 there is no longer a coverage gap (aka donut hole). So that’s the good news.

Instead of a coverage gap, you will pay your plan’s formulary tiered copayments until you’ve spent a total of $2,000 (in 2025) on covered medications. Once you’ve reached that Maximum out-of-pocket (MOOP) amount, you will pay $0 for covered medications for the rest of the plan year.  Please note the key word ‘covered’. You will need to find out from your plan or your pharmacy whether or not your medication is covered and at what formulary tier and copayment. If your medication is not covered by your plan, it will not count toward the annual MOOP. It will also only count toward the MOOP if it’s processed through your insurance. If you get a better price by using a discount card, it will not count toward your MOOP. 


If your medication is not covered, you can get a list of alternative options that would be covered and ask your doctor to prescribe one of those instead. If you absolutely NEED the medication that is not covered, your doctor can request a formulary exception to ask the insurance company to cover it anyway. In order for the insurance company to consider your request, you and your doctor will need to provide evidence that other treatments have been unsuccessful.

Getting the right prescription medication that works for you and with your insurance is a process. Then, once you’re settled into your plan, it will reset with plan, premium, pharmacy and formulary changes every year on January 1st. This is why it’s important to have a good Medicare insurance agent to help you through the process and changes each year.

Daintee Hurst Dietz · Answer

We must always get the drug name, preferred pharmacy and coverage area to review. In a traditional sense the gap is gone but not all plans center each drug. Trusted agent is important.

Rick Boyd · Answer

If you are referring to your initial deductible. If your medication is in your plans formulary, it will count for the deductible.

Bruce Kern · Answer

It will go toward the $2000 MOOP for drugs. Whether it is generic or name brand medication it counts toward  the $2000 cap.

Fred Manas · Answer

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.

Answered by Fred Manas on May 28, 2025

Agent Licensed in NY, CT, DC & 7 other states

Answered by Fred Manas Medicare Insurance Agent

Gary Henderson · Answer

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

Steve Brauer · 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.

Answered by Steve Brauer on April 14, 2025

Broker Licensed in AZ & CA

Answered by Steve Brauer Medicare Insurance Agent

Vachik Chakhbazian · Answer

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.

Answered by Vachik Chakhbazian on April 20, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Andrew Kramer · Answer

First, there is no more coverage gap (aka the donut hole) in 2025. That was ended by the IRA (Inflation Reduction Act in 2024). Now, the max out-of-pocket on Part D plans, whether stand-alone, or part of an Advantage plan, is $2,000/year. All Rx's purchased through the plan go towards that max. Anything that might be purchased outside the US, or using GoodRx, or any other discount plan, does not.

Answered by Andrew Kramer on May 21, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Sam Silva · Answer

In 2025, there’s no more coverage gap ("donut hole").

Medicare Part D has a \$2,000 out-of-pocket cap for the year.

Once you pay \$2,000 total out-of-pocket, you pay \$0 for covered drugs the rest of the year.

Your cholesterol medication costs do count toward that cap.

Check your Explanation of Benefits (EOB) to see how much you’ve spent so far.

Need help reviewing your medication or plan?  Call us.

Linda Davies · Answer

The coverage gap went away for 2025. There is now a $2000 max for prescriptions. As long as your cholesterol medicine is on your prescription drug plan formulary it will count towards the $2000 max. If your prescriptions were to reach/exceed $2000, your prescription
cost over $2000 would be zero dollars for the rest of the calendar year.

Tony Merwin · Answer

All med costs (that are covered on formulary) contribute towards your plan phases, whether it be deductible phase, initial coverage phase or catastrophic coverage phase. So if your cholesterol med is included in your plan's formulary, then yes.

Answered by Tony Merwin on June 26, 2025

Agent Licensed in TX, AR, AZ & 28 other states

Answered by Tony Merwin Medicare Insurance Agent

Philip Santucci · Answer

This is best discussed with an Agent or Broker to better understand your situation and give you the right answer.

Areasha Lockhart · Answer

This is going to depend on the Part D plan you choose. With my clients, i have them bring their Medications to their appointments so I can look their meds up to make sure they are covered with the plan they will choose. Each carrier has their own list of medications covered on their formulary. Stand-alone Prescription plans and Medicare advantage plans are all different in what they cover and consider for the coverage gap. My recommendation is to have your agent run your medications and they will be able to give you the exact answer to this question.

Answered by Areasha Lockhart on May 20, 2025

Broker Licensed in CO, IA & ME

Answered by Areasha Lockhart Medicare Insurance Agent

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?

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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?

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