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The Health Care Law and You

Savings You’ll See With Medicare Part D

The health care law and prescription drug discounts

Will I get a discount on all Medicare covered brand-name prescription drugs?

If a drug company has signed an agreement to participate in the Medicare Part D discount program, all of the Medicare-covered Part D brand-name drugs it makes are covered during the coverage gap for that calendar year. This includes prescription drugs on the plan’s list of covered drugs and those covered through an appeal.

Will I get additional savings if I have a Medicare drug plan that already includes coverage in the gap?

Yes. You may get a discount after your plan’s coverage has been applied to the price of the drug. The discount for brand-name drugs will apply to the remaining amount that you owe.

Do I still get the discount if I have insurance other than Medicare?

You can only get the discount if Medicare Part D pays first for your prescription drugs. If your other insurance coverage pays second, your other insurance coverage will pay after the discount has been applied.

Do I get the discount if I have drug coverage from a State Pharmacy Assistance Program (SPAP)?

If you’re enrolled in a State Pharmacy Assistance Program or any other program that provides coverage for Part D drugs (other than Extra Help), you still get the discount on covered  brand-name drugs. The discount is applied to the price of the drug before any SPAP or other coverage.

Will I also get the discounts if I get “Extra Help” from Medicare?

If you receive “Extra Help,” you aren’t eligible for additional discounts. Your drug costs when you are in the coverage gap are already covered by your existing discount program.

What will the discounts look like for the coverage gap over the next 10 years?

The coverage gap discounts will continue to increase until 2020, as shown in the chart below. In 2020 you will still be responsible for paying your premiums and deductible, as well as 25 percent of your prescription drug costs until you reach catastrophic coverage. If your costs exceed the catastrophic coverage level, you will only be responsible for 5 percent of your prescription drug costs for the rest of the year.

Doughnut Hole Discounts: Year by Year

Year You receive this percentage for brand-name drugs in the coverage gap You receive this percentage for generic drugs in the coverage gap
2013 52.5% 21%
2014 52.5% 28%
2015 55% 35%
2016 55% 42%
2017 60% 49%
2018 65% 56%
2019 70% 63%

Source: Centers for Medicare & Medicaid Services

Also of interest: More fact sheets about the health care law.

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