Prescription Drug Plans

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If you are already enrolled in a Part D “standalone” plan or a Medicare Advantage plan that incorporates drug coverage, you can switch plans during the open-enrollment period, which runs from Oct. 15 to Dec. 7 every year.

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    Costs in the Coverage Gap

    Costs in the coverage gap

    Brand-name prescription drugs

    Once you reach the coverage gap, you’ll pay no more than 25% of the cost for your plan’s covered brand-name prescription drugs. You’ll pay this discounted rate if you buy your prescriptions at a pharmacy or order them through the mail. Some plans may offer you even lower costs in the coverage gap. The discount will come off of the price that your plan has set with the pharmacy for that specific drug.
    Although you’ll pay no more than 25% of the price for the brand-name drug, almost the full price of the drug will count as out-of-pocket costs to help you get out of the coverage gap. What you pay
    and what the manufacturer pays (95% of the cost of the drug) will count toward your out-out-pocket spending. Here’s a breakdown:

    • Of the total cost of the drug, the manufacturer pays 70% to discount the price for you. Then your plan pays 5% of the cost. Together, the manufacturer and plan cover 75% of the cost. You pay 25% of the cost of the drug.
    • There’s also a dispensing fee. Your plan pays 75% of the fee, and you pay 25% of the fee.

    What the drug plan pays toward the drug cost (5% of the cost) and dispensing fee (75% of the fee) aren’t counted toward your 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.

    Generic drugs

    Medicare will pay 75% of the price for generic drugs during the coverage gap. You’ll pay the remaining 25% of the price. 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

    • Your yearly deductible , coinsurance, and copayments
    • 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 coverage gap

    • The drug plan premium
    • Pharmacy dispensing fee
    • What you pay for drugs that aren’t covered

    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.

    It pays to review your Part D coverage every year, especially if you have started taking new drugs.

    Choosing a good plan

    Start at Medicare.gov. To find the basics about the benefit and Part D plans at Contact Us. There’s a link to the Medicare Part D Plan Finder, which allows you to compare offerings and coverage options in your area and includes a helpful formulary finder that allows you to compare plans based on their coverage of your personalized list of drugs. It will even show you your monthly out-of-pocket drug cost for the year.

    Learn more. We recommend consulting the website of the nonprofit Medicare Rights Center. There you can find in-depth information on Medicare Part D.

    Getting Financial Help

    Individuals with annual incomes of less than $17,235 and financial resources of less than $13,300, or married couples with incomes of less than $23,265 and resources of less than $26,580, might qualify for Extra Help from Medicare to pay their Part D premiums and out-of-pocket drug costs.

    Download Medicare’s instructions on applying for the Extra Help program.

    Additionally, read about the six ways to lower your drug costs on Medicare.gov.

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