Many health insurance plans have limits on how much they will cover for prescription drugs. Medicare drug plans are no different. The good news is that Medicare drug plans provide special coverage if you have an unexpected illness or injury that results in extremely high drug costs.
This is called “catastrophic” coverage. It assures that once you have paid $3,850 out-of-pocket for drug costs in a calendar year, almost all of your drug costs above that amount are covered.
During the time between a drug plan’s standard level of coverage and the catastrophic coverage, you pay all of the costs for your drugs. This period is called the coverage gap (sometimes called the “doughnut hole”).
If you have limited income and resources, and qualify for full extra help, most of the information in this fact sheet doesn’t apply to you. You will continue to pay a small copayment or coinsurance amount during the coverage gap.
Tips for avoiding the gap
If your drug plan has a coverage gap, here are some ways you can avoid or delay entering the gap, and continue to save money on drug costs while in the gap:
- Use discount cards or other pharmacy discounts, and make sure to send receipts to Medicare so purchases count toward total out-of-pocket costs.
- Ask your doctor about generic or less-expensive brand name drugs that would work just as well as the ones you’re taking now. According to Consumers Union, switching to lower-cost drugs is often enough to help you avoid the coverage gap, and can save you hundreds or thousands of dollars a year.
- Look into other sources of “wraparound” coverage you may qualify for, such as from a current or former employer or union, or a State Pharmaceutical Assistance Program (SPAP). There are 21 states and one territory also offering wraparound coverage to help patients with drug plan premiums and/or cost sharing.
Note: Not all types of wraparound coverage will count toward your out-of-pocket coverage.
In Pennsylvania, PACE and PACENET will wrap around all Part D plans; however, the time frames for when this help begins will differ depending on what Part D plan you currently have.
|
PACE
|
PACENET
|
| Phone |
(800) 225-7223 |
Phone |
(800) 225-7223 |
| Where to apply |
PACE Program
1st. Health Services
4000 Crums Mill Road
Suite 301
Harrisburg , PA 17112 |
Where to apply |
PACENET Program
PO Box 8806
Harrisburg , PA 17105 |
- Look into Patient Assistance Programs that may be offered by the manufacturers of the drugs you take. Almost all of the major drug manufacturers are offering assistance programs for Medicare patients.
- Explore national and community-based charitable programs that might offer assistance, such as the National Patient Advocate Foundation or the National Organization for Rare Disorders.
- Check into getting extra help. If you have Medicare and have limited income and resources, you may qualify for extra help paying for your prescription drugs. Contact the Social Security Administration at (800) 772-1213; TTY users should call (800) 325-0778.
Remember, the coverage gap is temporary. After you have paid $3,850 out-of-pocket for drug costs in a calendar year, almost all of your drug costs above that amount are covered.
And, if you want to switch to a plan without a coverage gap, you can do so from Nov. 15-Dec. 31 of each year. Your coverage will start Jan. 1 of the following year.
For more information
All Medicare drug plans are different, so you should call your plan if you have questions about how the coverage gap will work for you. If you need help finding other resources, you can call Pennsylvania's APPRISE Health Insurance Assistance Program at (800) 783-7067 or Medicare at 1-800-MEDICARE; TTY users should call (877) 486-2048.
State Pharmaceutical Assistance Programs
www.shiptalk.org
Resources for Patient Assistance Programs
- Partnership for Prescription Assistance—Pennsylvania
www.pparxpa.org
Find contact information and applications for free or discounted programs in just four easy steps.
- RxAssist
www.rxassist.org
Offers a comprehensive directory of patient assistance programs.
- Medicare pharmaceutical assistance program search tool
www.medicare.gov/pap/index.asp
See if any programs are available for the drugs you are taking.
Charitable Programs
Additional links
Printable version of “Bridging the Coverage Gap”
The original source document from the Centers for Medicare and Medicaid Services is available below.
Some links require Adobe Acrobat Reader. Download it for free.
