What drug plans cover
Medication Therapy Management programs for complex health needs
Drug plan coverage rules
Using your drug plan for the first time
Filling a prescription without your new plan card
Costs for Medicare drug coverage
Monthly premium for drug plans
Yearly deductible for drug plans
Copayment/coinsurance in drug plans
Costs in the coverage gap
Part D late enrollment penalty
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs.
Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2018, once you and your plan have spent $3,750 on covered drugs, you're in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.
Brand-name prescription drugs
Once you reach the coverage gap in 2018, you'll pay no more than 35% of the plan's cost for covered brand-name prescription drugs. You get these savings if you buy your prescriptions at a pharmacy or order them through the mail. Some plans may offer higher savings in the coverage gap. The discount will come off of the price that your plans has set with the pharmacy for that specific drug.
Although you'll pay no more than 35% of the price for the brand-name drug in 2018, 85% of the price—what you pay plus the 50% manufacturer discount payment—will count as out-of-pocket costs which will help you get out of the coverage gap. These items aren't counted toward your out-of-pocket spending:
The amount Mrs. Anderson pays ($21.70) plus the manufacturer discount payment ($30.00) count as out-of-pocket spending. So, $51.70 counts as out-of-pocket spending and helps Mrs. Anderson get out of the coverage gap. The remaining $10.30, which is 15% of the drug cost and 65% of the dispensing fee paid by the drug plan, doesn't count toward Mrs. Anderson's out-of-pocket spending.
If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount after your plan's coverage has been applied to the drug's price. The discount for brand-name drugs will apply to the remaining amount that you owe.
In 2018, Medicare will pay 56% of the price for generic drugs during the coverage gap. You'll pay the remaining 44% of the price. What you pay for generic drugs during the coverage gap will decrease each year until it reaches 25% in 2020. The coverage for generic drugs works differently from the discount for brand-name drugs. For generic drugs, only the amount you pay will count toward getting you out of the coverage gap.
If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount after your plan's coverage has been applied to the drug's price.
Items that count towards the coverage gap
Items that don't count towards the coverage gap
If you think you should get a discount
If you think you've reached the coverage gap and you don't get a discount when you pay for your brand-name prescription, review your next "Explanation of Benefits" (EOB). If the discount doesn't appear on the EOB, contact your drug plan to make sure that your prescription records are correct and up-to-date.
If your drug plan doesn't agree that you're owed a discount, you can file an appeal.