What if I don’t get a discount but think I should have?

If you think you have reached the coverage gap but you haven't received a discount when you pay for your prescription, review your next Explanation of Benefits (EOB) notice. If the discount doesn’t appear on the EOB, work with your drug plan to make sure that your prescription records are up to date. If your drug plan doesn’t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) or by calling Medicare directly at 800-MEDICARE (800-633-4227).

Can I receive 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 is the secondary payer, 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 50 percent discount on covered brand-name drugs. The 50 percent discount is applied to the price of the drug before any SPAP or other coverage. For example, if you fill a $200 brand-name prescription, the cost of your prescription after the 50 percent discount would be $100. If you’re enrolled in an SPAP that reduces your cost-sharing for brand-name drugs by $25, you would pay the remaining $75 for the prescription. The $200 will count as out-of-pocket spending and help you get out of the coverage gap.

Will I receive the discounts if Medicare's Extra Help helps me pay my prescription drug costs?

If you receive Extra Help, you aren’t eligible for additional discounts because 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. 

Source: Centers for Medicare & Medicaid Services

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