Manage the Medicare Part D Coverage Gap

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.

Questions? Call UnitedHealthcare at:
1-877-699-5710
(TTY 711)
Hours: 8 a.m.-8 p.m. local time,
7 days a week

Have a reference number? Enter it here

Your Reference Number:
View saved info

Need help? Chat
live with a licensed sales agent.

  • View Plans & Pricing

    Find a plan in your area:
  • Need help finding a ZIP code? Look up a ZIP code

Update Adobe Flash Player

Your current version of Flash player is not supported. Please upgrade Flash player to the latest version.

Optional supplemental service (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage and fitness programs.

Optional supplemental service (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage and fitness programs.

Optional supplemental plan (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage, vision and hearing coverage and fitness programs.

Creditable Coverage

Refers to prescription drug coverage that offers benefits the same as or better than coverage available through Medicare.

Tier 1: Preferred Generic. Lowest Copay.

This tier includes lower-cost, commonly used generic drugs. Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2: Non-Preferred Generic. Low Copay.

This tier includes most generic drugs. Use Tier 2 drugs, instead of Tier 3 or 4, to help reduce your out-of-pocket costs.

Tier 5 : Specialty Tier. Coinsurance.

This tier includes unique and/or very high-cost drugs. You pay a percentage of the total drug cost, called coinsurance.

Tier 4: Non-Preferred Brand. Highest Copay.

This tier includes non-preferred generic and non-preferred brand drugs. Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Tier 3: Preferred Brand. Medium Copay.

This tier includes many common brand name drugs, called preferred brands, and some higher-cost generic drugs. Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4: Non-Preferred Brand. Highest Copay.

This tier includes non-preferred generic and non-preferred brand drugs. Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Drug List tool tip

A list of drugs covered by your Medicare Part D plan. A drug list may also be referred to as a covered prescription drugs list (CML), a preferred drug list (PDL), a select drug list or a formulary. These drugs are dispensed through participating network pharmacies to covered members. Drug lists may differ between Medicare prescription drug plans.


Carefully weigh the differences in drug lists against the plan costs and other features when choosing a plan that may best meet your needs. A drug list may change during the year.

Tier 2: Low Copay

This tier includes most generic drugs. Use Tier 2 drugs, instead of drugs in Tiers 3 or 4 to help reduce your out-of-pocket costs.

Coverage Gap Stage:

During the Coverage Gap Stage, you (or others on your behalf) 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.

You may pay less if your plan has better coverage in the gap.

Always use your Medicare Part D member ID card during the coverage gap to get the plan's discounted drug rates. The money you spend using your card counts toward your out-of-pocket costs.

Out-of-Pocket Costs:

The amount you (or others pay on your behalf) pay for prescription drugs starting January 1, 2013 not including premiums.

Premium (or monthly premium)

The monthly fee you pay for Medicare coverage.

Deductible/annual deductible

The pre-set, fixed amount you must pay for healthcare or prescription drug costs before Medicare or the plan begins to pay.

Deductible/Annual deductible

The pre-set, fixed amount you must pay for healthcare or prescription drugs costs before the insurance company or Medicare begins to pay.

Coinsurance

A kind of cost sharing where you pay a percentage of the cost of a service. For example, a plan might pay 75% and you would pay 25%. In Medicare Advantage, coinsurance varies depending on the plan.

Copay

A kind of cost sharing where you pay a predictable, pre-set amount for a service, such as an annual check-up.

Copay

A kind of cost sharing where you pay a predictable, pre-set amount for a service, such as an office visit.

Primary Care Physician's name and ID

Your primary care physician (PCP) plays an important role in your health care, and we want you to have the opportunity to select one you are comfortable with. Your PCP can:

  • Help you make good lifestyle choices to maintain and improve your health.
  • Serve as a direct point of contact in case of an emergency.
  • Manage the drugs prescribed to you and identify potential adverse interactions.
  • Coordinate the care of specialists who may diagnose and treat your conditions.
  • Help ensure that you are getting the care you need while helping to minimize your out-of-pocket costs.

Retrieve saved information

You can retrieve information you've entered on previous visits by entering your reference number.

Go
Example : AB123456

Update Adobe Flash Player

Your current version of Flash player is not supported. Please upgrade Flash player to the latest version.