All Part D drug plans offer significant discounts on both brand name and generic drugs while you are in the coverage gap. Also, the coverage gap is limited by its design, so don’t worry too much. Let’s explain how drug plans work so that you can rest easy that entering the coverage gap won’t bankrupt you.
In 2006, when Medicare Part D drug plans first became available, there were a few carriers who offered plans that covered both generic and brand name drugs during the coverage gap, or donut hole. The following year, most of those carriers changed that and today, almost no drug plans offer comprehensive brand name cover in the coverage gap.
The reason this should not be a cause for concern is that the Center for Medicare and Medicaid Services has created financial protections for you that are built in to every Part D plan. Each carrier that chooses to offer Part D drug plans must conform their plan to meet the basic minimum criteria set by the federal government.
So, although all Part D plans have a coverage gap, they also all have a Catastrophic Coverage limit at which your drug spending is enormously reduced. This is designed to help protect you from facing financial bankruptcy due to very expensive brand name medications.
Generic drug coverage in the gap
Some Medicare drug plans do offer copays instead of just discounts for generic drugs in the gap. However, because so many pharmacies offer a wide range of generic drugs for $4 right at the pharmacy counter, the Part D drug coverage of generics during the gap doesn’t always help you, and may actually hurt you if you pay a considerably higher premium for that drug plan just because it covers some generic drugs in the gap.
The best way to evaluate which drug plan in your state will be the most competitive for you is to use Medicare’s own drug plan finder tool. This search engine will compare all the drug plans in your state and tell you which ones will be cost effective for you.
Brand name drug coverage in the gap
As with generics, brand name drugs have discounts in the gap so that you never have to pay 100% of the cost for a covered formulary medication when you are in the gap. These discounts are significant too – more than 50% of the cost of the medication, so while what you pay might not be as low as the copay you paid before the gap, you won’t be paying full price either.
We can help you
At Boomer Benefits, we run this Medicare drug plan analysis for free for any of our Medigap policyholders. As agents, we are aware of things about the plans that you may not be, such as whether a certain carrier will require prior authorization or impose quantity limits on one of your prescriptions. We can also tell you whether a plan employs “step therapy” on any of your medications. Step therapy is when the plan declines to cover a more expensive medication when alternative medications exist that treat the same condition.
Knowing whether you will face these kinds of restrictive management tools on certain plans is very helpful up front so you can have as little hassle as possible at the pharmacy. We can also inform you about Medicare Savings programs that you may qualify for that would eliminate the coverage gap for you.
Don’t head into your drug plan blind-folded – contact our agency for help today!