Costs in the Drug Plan, Part D Coverage Gap

Costs in the Part D Coverage Gap

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. Once you enter the coverage gap, you get a 50% manufacturer-paid discount on covered brand-name drugs. Although you’ll only pay 50% of the price for that brand-name drug, the entire price will count as out-of-pocket spending, which will help you get out of the coverage gap. You’ll also save 7% of the plan’s cost for all generic drugs until you reach the end of the coverage gap.

Items That Count Towards the Part D Coverage Gap:

  • Your yearly deductible, co-insurance, and co-payments
  • The discount you get on brand-name drugs in the coverage gap
  • What you pay in the coverage gap

Items That DON’T Count Towards the Part D Coverage Gap:

  • The drug plan premium
  • What you pay for drugs that are not covered

5 Ways to Lower Your Costs in the Coverage Gap

1. Consider Switching to Generics or Other Lower-Cost Drugs. Talk to your doctor to find out if there are generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now. You might also be able to save money by using mail-order pharmacies. Learn more in the Medicare Plan Finder.

2. Pharmaceutical Assistance Programs. Some pharmaceutical companies offer help for people enrolled in Medicare Part D. Find out whether there’s a Patient Assistance Program for the drugs you take by visiting our Pharmaceutical Assistance Program site.

3. State Pharmaceutical Assistance Programs. Many states and the U.S. Virgin Islands offer help paying drug plan premiums and/or other drug costs. Find out if your state has a program by visiting our State Pharmaceutical Assistance Program site.

4. Apply for Extra Help. Medicare and Social Security have a program for people with limited income and resources that helps you pay for your prescription drugs. If you qualify, you could pay between $1-$6 for each drug. Apply with Social Security by visiting www.socialsecurity.gov or by calling 1-800-772-1213.

5. Explore National and Community-Based Charitable Programs. National and local charitable groups (like the National Patient Advocate Foundation or the National Organization for Rare Disorders) may have programs that can help with your drug costs. Learn about programs in your area on the Benefits Check-up website.

Some Part D Drug Plans Offer Additional Gap Coverage.

  • There are plans that offer additional coverage during the gap, like for generic drugs. However, plans with additional gap coverage may charge a higher monthly premium.
  • Check with the drug plan first to see if your drugs would be covered during the gap.  Talk to your doctor or other health care provider to make sure you’re taking the lowest cost drug available that works for you. You may also be able to save money during the gap in other ways.
  • More Savings in the Gap Coming Through 2020
  • In addition to the 50% discount on covered brand-name prescription drugs, the percentage you save in the coverage gap will increase each year through 2020.
  • After the Gap: Catastrophic Coverage
  • Once you get out of the coverage gap, you automatically get “catastrophic coverage.” It assures you only pay a small co-insurance amount or co-payment for covered drugs for the rest of the year.