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 67 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!
I just got a question that came in. I just started a new Part D drug plan and my new cholesterol medication. Does that count towards my coverage gap? Yes, it does. Any of the medications that you're taking, as long as they are in the formulary with that particular drug plan, will be covered through that deductible and the max out-of-pocket each and every year.
But it is important that each and every year during the annual enrollment, which starts October 15th and runs to December 7th, you reevaluate your drug plan to make sure it's meeting your needs. The best way of doing that is to sit down with a licensed Medicare agent, who will go over and be able to understand what your medications are so you can select the right drug plan for you. I hope this helps.
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.
Yes, your cholesterol medication will be covered under your program. However, there are a number of cholesterol medications. You need to call the plan you are in and find out. Sounds like you are on a Medicare Supplement plans for parts A&B. I would call your company that administers your plan.
This is a very loaded question. First of all, the "donut hole" (sometimes referred to as the coverage gap) was done away with in 2025. The out of pocket maximum would apply toward your medication if it is on your insurance company's formulary (list of drugs that are covered). If the drug is "NOT COVERED" then neither will it apply to the yearly maximum. I really would consult an agent if there is a question or concern
Great question! When you have Medicare Part D, all covered prescriptions, including cholesterol medications, count toward your coverage gap (or “donut hole”) total. This means the amount you spend on your drugs adds up until you reach the gap threshold. Once in the coverage gap, you’ll typically pay 25% of the cost for both brand-name and generic drugs until you reach the catastrophic coverage limit, then your costs drop again.
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.
The question is they have a new cholesterol drug and they want to know if it will count towards your coverage gap. Okay, well, there is no coverage gap. That's over now, also known as the donut hole. That ended on January 1, 2025. So the real question here is, is your drug covered? Most of these statins that cover cholesterol, we're talking atorvastatin, rosuvastatin, simvastatin, and pravastatin, are covered by all Medicare Part D prescription drug plans, and they're very low cost. Many of the Part D plans will have these meds listed under a tier one or a tier two. With many of the plans, you'll pay a very low, single-digit dollar co-pay or no cost at all. So you're really in good shape. You can check a plan's formulary to find out if the drug is covered. The real question is, is the drug covered, not will it count towards the coverage gap? There is no coverage gap, so the drugs are generally covered. Check with your plan's formulary. You can go to medicare.gov, which is a public website, click on Find a Plan Now, and then type in your ZIP code and the name of the drug. You will see right away which plans cover your drugs and what your co-pay will be, whether you're going to use a mail order or local pharmacy. It sounds a little complicated, but it really isn't. I think the best thing to do is to contact an experienced Medicare agent who is independent. I can think of at least one person like that you can call who can help you with that.
The coverage gap is the "donut hole" which was stopped in 2025. Your agent should have told you this and i also hope your agent reviewed your formulary and plan info before signing you up.
Yes, all medications count towards your maximum out of pocket which is $2000. There is no longer a donut hole, so your copay plus the insurance’s cost will
As long as your cholesterol medication is covered by your Medicare Part D insurance plan, then it will count towards your coverage gap. If any prescription is not covered by the Medicare Part D plan, then it will not count towards the coverage gap. If need more details, please feel free to give me a call.
Yes if your new cholesterol medication is covered by your Part D plan, the full retail cost of it counts toward moving you into the coverage gap, not just your copay. So even if you’re only paying a small amount at the pharmacy, the plan may be paying much more behind the scenes and that total is what pushes you through the phases. Once you reach the gap, you’ll usually pay about 25% of the drug’s cost until you move into catastrophic coverage. If you’re not sure whether the drug is on your plan’s formulary, it’s worth double-checking because non-covered drugs don’t count the same way.
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.
Not sure what prescription plan you are currently on, every plan is different. To answer your question, as long as the cholesterol medication that you are on is covered under your current prescription plan, it will count towards your coverage gap. Also, if this is a standalone prescription plan, it is highly recommended to have your prescription plan reviewed on a yearly basis, depending on the medications you are currently taking. This is because each plan is different, along with the formularies within each plan.
If your cholesterol medication is on your Part D plan’s formulary (drug list), then what you and the plan pay for that medication counts toward your total drug spending, which is what pushes you into the coverage gap
The great news is that the Coverage Gap is gone as of January 1st, 2025.
Now, how your cholesterol medication is covered but your specific plan is a bit more nuanced depending on which medicine and which plan. Often cholesterol meds, like Atorvastatin, are very low cost but I can get you an exact quote at any time.
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.
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.
The coverage gap was eliminated beginning with the 2025 plan year. But in answer to your question for last year's plan, yes, Part D copays counted towards the gap dollar limit.
You have asked a very good question! I am happy to communicate orally. Texting is not as fun.
Since I am not allowed to ask you to call me, you have another choice. I will be honored to answer all of your questions orally but texting wears me out.
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.
Yes, for as long as the cholesterol medication that you are on is covered under your current prescription plan, it will count your out of pocket which includes the coverage gap.
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.
Th e coverage gap was discontinued in 2025 which was replaced by an out-of-pocket maximum amount which is $2100 for 2026. When you reach your out-of-pocket maximum, you enter the Catastrophic Coverage Phase, and you won't pay anything for your covered medications for the remainder of the year.
Hello and thank you for asking for our assistance with your question. Your cholesterol medication coverage depends on if it's in the formulary of medication is listed in that particular Part D drug plan. If it is in the formulary and you use your Part D drug plan to purchase that medication it does accumulate to the $2000 maximum out-of-pocket limit for 2025.
When people reach the $2000 maximum amount of pocket while using their Part D formulary, their medication will be no cost to the member.
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.
Yes, it does. All prescription meds you get through your PART D plan go into the sum total that make up the maximum-out-of-pocket that is your 'coverage gap'.
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.
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.
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
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.
Yes, your cholesterol medication can count toward your Medicare Part D coverage gap - but in 2025, the rules have changed. The traditional "donut hole" is gone, and now your out-of-pocket costs are capped at $2,000 for the year.
There is no longer a coverage gap for 2025 nor 2026. If you have an agent they can help you with that as well as you can call you plan- member services, for that information.
Every drug covered by your prescription drug plan accumulates until you reach $2100. Once you reach your drug out of pocket max, you e ter the catastrophic phase and pay $0 for all prescriptions that year. It reset every January
Medications that are covered on your policies formulary and are purchased using you Part D plan all count towards your maximum out of pocket. as of 2025 there is no coverage gap.
Whether any medication is covered and counts towards your maximum out of pocket, you would need to check the plan’s formulary. But your question states coverage gap, not out of pocket. As of 2024, there is no more coverage gap or donut hole.
There is no longer a coverage gap on Part D. Some plans have a deductible up to $615 and the maximum out of pocket of $2000 for 2025 and $2100 for 2026. It will depend on your plan whether the cost of the drug will go towards your deductible (if applicable) or straight to your maximum out of pocket cost. It's best to call your agent or carrier for clarification.
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.
Yes, your cholesterol medication counts toward your Medicare Part D out-of-pocket spending, which is a key component for progressing through the coverage stages. As of 2025, the "coverage gap" or "donut hole" has been eliminated and replaced by a new $2,000 annual out-of-pocket spending cap. Once you hit this cap, you will enter catastrophic coverage, where your covered medications will have no copayments or coinsurance for the rest of the year.
Robert Remin, expert Medicare plan advisor, licensed in NY, CT, NJ, and FL. There is no coverage gap as of 2025 and if it's one of the basic cholesterol medications ie Tier 1 or Tier 2 cost will be very low so you will not come close to what is known as catastrophic coverage on your drug plan
for Medicare drug plans, what counts toward your coverage gap is the total cost of your covered drugs under your Part D plan. --both what you pay and what the plan pays --as long as the drug is on your plans formulary. So if your new cholesterol medicine is a covered drug on your plan, the cost of it will go toward moving you through the stages, including the coverage gap.
I can see how that may be confusing. As of 2025 there is not a coverge gap any longer. There is a deductible (if your plan has one), initial coverage where you pay for a portion of your prescriptions up to the maximum out of pocket of $2,000. Once your out of pocket costs reach $2,000 (in 2025) your plan then covers your covered medications at 100%.
So, if your cholesterol medication is covered by your plan, it will count toward your maximum out of pocket.
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.
All the answers for Medicare part D can be found on medicare.gov. Most of the prescription companies have taken away the rights of agents to guide our clients with part D plans. So I assist my clients pro bono to help them. Find the right plan for themselves.
In 2025 Medicate eliminated gap there is no more gap in 2025
Also your cholestrol medication would count toward your maximum out of pocket once you have reached maximum out of pocket spending your medication becomes 0 dollar cost to you
Your out of pocket Medicare prescription drug costs count towards your $2,100 max costs for 2026. Make sure the drugs fall within the formulary of your PDP plan.
Yes, any formulary drug will count toward the total out of pocket of $2,100 annually.
There is no gap. You meet the deductible, then enter the initial stage 2 where you pay 25% of the cost of the drug, then you enter stage 3 which is the catastrophic stage. At $2,100 out of your pocket you pay nothing for the rest of the year.
If you are confused about if your cholesterol medication counts towards your coverage gap, check your current evidence of coverage document (also known as a member service agreement) and find the section labelled "prescription drugs".
Your evidence of coverage document will tell you whether or not covered prescriptions under your prescription drug plan count toward your coverage gap as well as other information you may not know about your prescription drug plan.
This can be tricky. Most cholesterol medication is covered by part D and does count towards the maximum out of pocket. However, there is no longer a coverage gap in part d plans.
Yes, your new cholesterol medication will count towards your True Out Of Pocket (TROOP) expense as long as your new medication is on your plan's formulary. If it is not on the formulary, it does not count in your favor during your coverage gap. The coverage gap is the difference between $0 spent (January 1st of each year) until your TROOP meets the coverage cap. In 2025, that cap is set at $2000, in 2026 it will be $2100.
Yes, almost every prescription you fill under your part D plan counts toward the spending that moves you into the coverage gap. What you pay and what your part D plan pays both add up toward the dollar limit that triggers the coverage gap.
Over the counter drugs, vitamins or medications not covered by your plan does not count
If your new prescription medication is on the drug insurance plan's formulary (list of medications covered by the plan), it will count towards the true out of pocket maximum costs for drugs. The true maximum out of pocket costs for 2026 will be capped at $2,100. This is the most a Medicare beneficiary will pay over the course of the year towards their prescription drug costs. This amount is calculated by adding any amount paid towards a deductible, copay and coinsurance. Once the beneficiary has paid $2,100 towards their prescription medication costs, they should not have any additional costs for prescriptions covered by the Medicare Part D Insurance plan.
As of 2025 Medicare does not have a coverage gap. Medicare now has a Maximum out of pocket for your prescriptions of $2500. This means once you're out of pocked cost for your prescriptions equal $2100 then for the remainder of the year you will not have to pay anything for any Medicare covered Prescriptions.
