Understanding the Medicare Part D Coverage Gap (“Donut Hole”)

The Coverage Gap, or “Donut Hole,” can be confusing. Many people never reach the Gap, but it’s important to understand how it might affect your prescription drug costs.

All Medicare Part D plans have four coverage stages:1

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  • Some plans require you to pay a deductible of up to $415 before your plan will begin to pay its share of your covered drugs.
  • Most SilverScript (PDP) members have no deductible for any drug on any tier,2 so your plan begins sharing the cost of your covered drugs the day your coverage begins.
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Initial Coverage

  • You will usually pay a copay or coinsurance for your covered drugs during this stage, based on the drug tier in your Part D plan’s list of covered drugs (formulary).
  • Once you and your plan have spent $3,820 on your covered drugs, you enter the next stage, known as the Coverage Gap, or “Donut Hole.”
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Coverage Gap (“Donut Hole”)

  • What you pay for your drugs in the Gap depends on whether or not your plan includes coverage in the Gap.
  • For beneficiaries in plans without additional Gap coverage, you will pay 25% of the cost for covered brand drugs and 37% of the cost for covered generic drugs.
  • You remain in the Gap until the total amount you have spent on your covered prescription drugs, including the amount anyone else has paid on your behalf, plus the discount you get on brand drugs while in the Gap, reaches $5,100.
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Catastrophic Coverage

  • When you exit the Coverage Gap and enter the Catastrophic Coverage stage, you pay a small coinsurance or copayment for covered drugs for the rest of the year.
  • If you reach this stage, you will remain in it until the end of 2019.

Regardless of which stage you reach in 2019, you will return to the Deductible stage on January 1, 2020.

SilverScript helps you track your progress toward the Coverage Gap

For each month that you use your coverage, SilverScript provides an Explanation of Benefits (EOB) statement. You may receive these by mail, or you can find up to 36 months of online statements securely stored in your  Caremark.com  account. Refer to your most recent EOB to confirm which coverage stage you’re in and to keep track of your progress toward the Gap.

Looking for ways to reduce paper clutter and stay organized? Go paperless by opting in to view your EOB statements online at your convenience. Log in to your  Caremark.com  account to opt in, and we’ll send you an email to let you know when a new EOB statement is available to view online. Click the link in your email to access, view and print your current EOB statement, plus up to three years of your EOB history. (You can opt out and return to paper statements at any time.)

Why does my SilverScript plan have a Coverage Gap?

Medicare created the four coverage stages - including the Coverage Gap - that are part of all Part D plans, not just SilverScript plans. Some plans offer additional coverage in the Gap, such as SilverScript Plus (PDP).3

What is included in the Initial Coverage Limit of $3,820 that puts me in the Gap?

This amount, sometimes referred to as “Total Drug Costs,” includes all deductibles, copays and coinsurance you have paid in the current plan year, plus the amount your Part D plan has spent toward the cost of your covered drugs in the current plan year.

What is included in the $5,100 that takes me out of the Coverage Gap and into the Catastrophic Coverage stage?

This amount, sometimes called “True Out-of-Pocket” or “TrOOP,” includes the deductibles, copays and coinsurance you have paid in the current plan year, plus the discount on brand drugs you receive while in the Coverage Gap, plus any amount paid on your behalf by other organizations.

Does my monthly premium count toward the drug costs that move me in and out of the Coverage Gap?

Your monthly premium payments are not included in your Total Drug Costs or TrOOP.

Is there any way I can avoid the Coverage Gap?

You may be able to delay your entry into the Gap, or avoid it completely, by choosing less expensive drugs when possible. Check with your doctor to find out whether a different drug is covered by your plan that will cost you less and is appropriate for your treatment.

1 Some individuals who receive Extra Help do not progress through the Medicare Part D coverage stages.

2 SilverScript Choice members in Colorado, Georgia and Texas: $0 deductible applies to drugs on Tiers 1 and 2, and $100 deductible applies to drugs on Tiers 3, 4 and 5. SilverScript Choice members in Arizona and South Carolina: $0 deductible applies to drugs on Tiers 1 and 2, and $415 deductible applies to drugs on Tiers 3, 4 and 5. SilverScript Choice members in Alaska: a $415 deductible applies to all drugs.

3 SilverScript Plus (PDP) is not available in Alaska.

Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.

This information is not a complete description of benefits. Call 1-866-235-5660 (TTY: 711) for more information , 24 hours a day, 7 days a week.

The formulary may change at any time. You will receive notice when necessary.

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