How is the coverage gap determined?

The coverage gap begins after you and your drug plan have spent a certain amount on covered drugs. Most Medicare drug plans have a coverage gap (also called a Medicare “period of no coverage”). This means that there is a time limit on how much the drug plan will cover for drugs. Not everyone will fall into the coverage gap, and it doesn't apply to members who get extra help paying for Part D costs.

Many Part D plans have a built-in coverage gap that temporarily limits the amount their insurance will pay for prescription drugs. You can compare prescription drug plans each year to make sure that your plan offers the best coverage for your drugs. It also calculates your out-of-pocket costs per month and shows how much you would pay in each of the coverage phases of each plan. Even though the initial coverage period has closed, you may still see a difference in cost between the initial coverage period and the initial coverage period.

Now, their share of the costs of the coverage gap is limited to 25% for both brand-name and generic drugs. The period of no coverage or period without coverage under Medicare Part D is the phase of Part D coverage after the initial coverage period. When Medicare Part D was first implemented, plan members who were in this gap had to pay the full cost of covered drugs until their total costs could qualify for coverage for catastrophic cases. For generic drugs, Medicare pays 75 percent of the cost while you're within the coverage gap; you pay the remaining 25 percent.

Before Part D was introduced, Medicare beneficiaries used to pay all the costs of their prescription drugs that weren't included in Medicare Part B, unless they had coverage from another source, such as retiree insurance or a Medigap plan. When you choose a Part D plan, the Medicare plan finder can show you when you are likely to enter and leave the period without coverage based on the costs that each plan in your area charges for your drugs. This coverage gap opens after the plan's initial coverage limits have been reached and before the catastrophic coverage takes effect. Drug manufacturers pay 70 percent of the insurer's negotiated cost of brand-name drugs to discount what you pay to cover the coverage gap.

Costs that don't help you get catastrophic coverage include monthly premiums, what your plan pays for drug costs, the cost of uncovered drugs, the cost of drugs covered at pharmacies outside your plan's network, and the generic 75% discount. Check your proof of coverage or call customer service at the number on the back of your Humana identification card to confirm that your plan will cover the service. However, your monthly Part D premiums, any part of the costs your drug plan pays, and what you pay for uncovered drugs won't be counted to help you bridge the coverage gap.

Gertraude Jackel
Gertraude Jackel

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