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 15 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.
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.
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.
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.
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.
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.
