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the medicare drug plan
6 Key Facts

1. Anyone on Medicare can get coverage regardless of income or health.

2. You are not obligated to enroll, but there may be consequences if you don't sign up when you are first eligible to do so.

3. To get Medicare drug coverage, you must select one approved private drug plan among many offering different choices. There is no single government plan.

4. Is your income limited? If you qualify for a part of the program known as "Extra Help." you'll pay very little for your medications.

5. Are your drug costs very high? You'll pay no more than 5 percent of the cost of each prescription after you've spent a certain amount of money out-of-pocket in any one year.

6. Do you have better drug coverage already? You probably won't need Medicare's Part D coverage. But it's wise to check.

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Medicare Prescription Drug Coverage Guide

Part 3: Moving In and Out of the Doughnut Hole

Navigating the Part D coverage gap

How do I get drugs during the drug coverage gap?

You can continue to get them through your plan at the price your plan has negotiated with the manufacturers, which is usually less than you'd pay retail. Your plan will track your expenses so they count toward the out-of-pocket limit. In the gap, you may find drugs elsewhere that are less expensive than your plan charges. You can buy these if you wish — but, under Medicare rules, only drugs purchased at pharmacies within your plan’s network count toward the limit that gets you out of the gap.

What counts toward my out-of-pocket spending limit?

  • Your deductible (if your plan has one);

  • Your copays during the initial coverage period;

  • The full price of the brand-name drugs you buy in the gap, even though you have not paid full price for them;

  • Any payments for your drugs made by a family member or friend, a charitable group or a state pharmacy assistance program.

In all cases, only payments for drugs your plan covers on its formulary (including any “exceptions” you receive) and are purchased from a pharmacy in your plan’s network count toward the limit.

What does not count toward my limit?

  • Your plan's premiums;

  • Payments for drugs not covered by your plan;

  • Payments for drugs bought at a pharmacy outside your plan’s network;

  • Payments made by your plan, by an employer, union, federal agency or other group insurer;

  • Discounts on generic drugs in the gap that are provided by the federal government;

  • The value of free or low-cost drugs provided by a drug manufacturer’s assistance program;

  • The value of drug samples provided by a doctor free of charge;

  • Any drugs bought from Canada or other foreign countries.

Will it take me longer to reach catastrophic coverage than before?

No.  The discounts you get in the gap will not slow you down in reaching low-cost catastrophic coverage.  That’s because the full cost of brand-name drugs bought in the gap count toward the dollar limit that triggers catastrophic coverage

How do I get these discounts?

You don’t have to apply for them.  They will be automatically deducted from the full price of your drugs at the pharmacy where you fill your prescriptions.

Can I delay reaching the gap?

Yes. Using lower-cost drugs will make your initial coverage last longer. Ask your doctor if generics or less-expensive brand-name drugs would work just as well as the ones you now take. Choosing these drugs could also reduce your copays. (For information on how similar drugs compare in effectiveness, go to the Consumer Union’s website.)

Next: What to do if you can't afford your drugs. »

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