What costs do NOT count as out-of-pocket expenses?


Many drug costs do not count toward getting out of the donut hole:

• Payments made by group health plans (such as retirement coverage provided by a former employer or union).

• The portion of generic drug costs in the donut hole paid by federal subsidies. Only the costs paid by beneficiaries for these drugs will be counted toward getting out of the coverage gap.

• Drug costs covered by government programs such as TRICARE, Black Lung, the Department of Veterans Affairs or federally-supported community health centers.

• Payments made from Workers’ Compensation.

• Costs covered by automobile, no-fault or liability insurance.

• Costs covered under any other third-party payment arrangement.

• Drugs purchased outside the United States.

• Drugs not on the plan’sformulary(unless you have received an exception).

• Drugs explicitly excluded from Medicare drug coverage, even if your plan has enhanced coverage to include them.

• Drugs provided by a pharmaceutical manufacturer’s patient assistance program.

Note also — the amount you pay for your monthly Medicare Part D premium does NOT count as an out-of-pocket expense.