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. Get your plan’s contact information from a Personalized Search (under General Search), or search by plan name. If your drug plan doesn’t agree that you’re owed a discount, you can file an appeal.
What’s Medicare Supplement Insurance (Medigap)?
Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share.
The Medicare Part D Coverage Gap (“Donut Hole”)
Coverage gap, also known as the “donut hole”: While in the coverage gap, you’ll pay 45% of the plan’s cost for brand-name drugs and 58% of the plan’s cost for generic drugs in 2016. You’re out of the coverage gap once your yearly out-of-pocket drug costs reach $4,850 in 2016. Once you have spent this amount, you’ve entered the catastrophic coverage phase. The costs paid by you or someone on your behalf (such as a spouse or loved one) for Part D medications on your plan’s formulary, or list of covered drugs, will count toward your out-of-pocket costs and help you get out of the coverage gap* Additionally, manufacturer discounts for brand-name drugs count towards reaching the spending limit that begins catastrophic coverage. If your plan requires you to get your prescription drugs from a participating pharmacy, make sure you do so, or else the costs may not apply towards getting out of the coverage gap. Keep in mind that costs that are paid for you by other insurance you may have, such as prescription drug coverage through an employer, won’t count towards your out-of-pocket spending.
Medicare Part D coverage gap
The Medicare Part D coverage gap (informally known as the Medicare donut hole) is a period of consumer payment for prescription medication costs which lies between the initial coverage limit and the catastrophic-coverage threshold, when the consumer is a member of a Medicare Part D prescription-drug program administered by the United States federal government. The gap is reached after shared insurer payment – consumer payment for all covered prescription drugs reaches a government-set amount, and is left only after the consumer has paid full, unshared costs of an additional amount for the same prescriptions. Upon entering the gap, the prescription payments to date are re-set to $0 and continue until the maximum amount of the gap is reached: copayments made by the consumer up to the point of entering the gap are specifically not counted toward payment of the costs accruing while in the gap.
About the Medicare Part D Coverage Gap
The Medicare coverage gap is the phase of your Medicare Part D benefit when there is a gap in prescription drug coverage. During this phase, you will have to pay more for your drugs, until you reach the catastrophic coverage phase. Most Medicare Advantage Prescription Drug plans and Medicare Prescription Drug Plans have a coverage gap, or “donut hole.” The coverage gap is reached when your total drug costs (what you and your plan pay) reach a certain amount. You then pay for your prescriptions out of pocket until entering the plan’s catastrophic coverage phase. This is when your total out-of-pocket costs, including the annual deductible and copayments/coinsurance, reach $4,850 in 2016.
Medicare: What Are Medigap Plans?
However, you may have to wait up to six months for coverage if you have a pre-existing health condition. The insurer through which you buy your Medigap policy can refuse to cover out-of-pocket costs for pre-existing conditions during that period. After six months, the Medigap policy must cover the pre-existing condition. The exception to this rule is if you buy a Medigap policy during your open enrollment period and have had continuous “creditable coverage,” or a health insurance policy for the six months before buying a policy. The Medigap insurance company cannot withhold coverage for a pre-existing condition in that case.
Part D Information for Pharmaceutical Manufacturers
The Medicare Coverage Gap Discount Program (Discount Program) makes manufacturer discounts available to eligible Medicare beneficiaries receiving applicable, covered Part D drugs, while in the coverage gap. In order to participate in the Discount Program, manufacturers must sign an agreement with CMS to provide the discount on all of its applicable drugs (i.e. prescription drugs approved or licensed under new drug applications or biologic license applications). Beginning in 2011, only those applicable drugs that are covered under a signed manufacturer agreement with CMS can be covered under Part D.
Medicare Part D Donut Hole – Prescription Drug Coverage Gap
Most Medicare Part D Prescription Drug Plans have a coverage gap, sometimes called the Medicare “donut hole.” This means that after you and your Medicare drug plan have spent a certain amount of money for covered prescription drugs, you then have to pay all costs out-of-pocket for the drugs, up to a certain out-of-pocket limit. The yearly deductible, coinsurance, or copayments, and what you pay while in the coverage gap, all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium.