What is the coverage gap?
Once you (or others on your behalf) and your Medicare Part D plan have collectively spent $2,8501 in 2014 on prescription drugs, you fall into the “coverage gap.” During the coverage gap, you will pay no more than 72% of the total cost for generic drugs or 47.5% of the total cost for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $4,550 in year-to-date out-of-pocket costs.
After reaching your out-of-pocket limit, you leave the gap and enter the catastrophic coverage stage. You pay a small copay or coinsurance and your prescription drug plan pays the remainder of the costs for each covered prescription drug until the end of the year with no limit.
Delay the gap
If your plan does not offer coverage through copays or coinsurance in the gap, then the best way to manage the added costs associated with the Part D coverage gap is to delay it. You may be able to do this by lowering your total drug costs.
Consider these money-saving tips:
- Switch to Tier 1 or Tier 2 drugs for reduced copays and costs. Ask your doctor about lower-tier drugs that may be right for you.
- Review current medications. Work with your doctor to eliminate prescriptions that are no longer necessary.
- Fill new prescriptions in small amounts. Commit to larger quantities when you know how you respond to the medication.
- Go to pharmacies in your network to receive the plans' discount price on your covered prescription drugs.
- Use a mail service pharmacy. Prescription-drug mail services, which deliver directly to your door, may save you money on your medications.
- Use the Preferred Retail Pharmacy Network. If you have a Medicare prescription drug plan, you can save money on your copays if you choose to fill your covered prescriptions at a preferred retail pharmacy.
- Use Pharmacy Saver™. If you have a Medicare Advantage Prescription Drug plan, see if any of your drugs qualify for Pharmacy Saver™ pricing. Hundreds of generic drugs cost as low as $2 at certain pharmacies with the Pharmacy Saver program.2 Plus, Pharmacy Saver pricing applies during the coverage gap.
- Track and manage your expenses. Monitor your monthly drug spending to see how close you are to the coverage gap. This may help you decide if you need to ask your doctor about lower-tier drugs.
When you're in the gap, use your Medicare Part D member ID card to receive the plan's discounted drug rates. Using your member ID card also ensures that the money you spend is correctly tracked toward your out-of-pocket costs, to help you get out of the coverage gap sooner.
1Dollar amounts valid for 2014
2Drugs and prices may vary between pharmacies and are subject to change during the plan year. Prices are based on quantity filled at the pharmacy. Quantities may be limited by pharmacy based on their dispensing policy or by the plan based on Quantity Limit requirements; if prescription is in excess of a limit, copay amounts may be higher. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayment/coinsurance may change on January 1 each year.
Other pharmacies are available in our network. Members may use any pharmacy in the network, but may not receive Pharmacy Saver pricing. Pharmacies participating in the Pharmacy Saver program may not be available in all areas.