Medicare and Healthcare Reform

What changes in coverage gap can I expect for 2016 as a result of Health Care Reform?

Manufacturer discounts will continue to be applied when you reach the coverage gap. In 2016, you will pay 45% of the cost of brand-name drugs and 45% of any dispensing fees and vaccine administration fees.

  • The discount will automatically be applied when you reach the coverage gap at the time you fill your prescription at a network pharmacy.
  • Your Explanation of Benefits (EOB) will identify the discount you received. And, both the manufacturer discount and what you pay are both applied to your out-of-pocket expenses and moves you through the coverage gap to catastrophic coverage.
  • You will also continue to receive a discount for generic drugs when you are in the coverage gap. For 2016, you will pay a coinsurance amount of 58%.
  • The amount paid by the plan does not count towards your out-of-pocket costs. Only the amount you pay and the manufacturer discount will count towards these costs and move you though the coverage gap.The dispensing fee is already included in the cost of the drug.

If you are already receiving Extra Help (also called Low Income Subsidy, or LIS) these changes do not apply since you already receive coverage in the gap.

What counts toward my true out of pocket (TrOOP) costs?

Medicare has rules that each Part D plan must follow when we keep track of your out-of-pocket costs for your drugs.

The following payments count towards your out-of-pocket costs as long as they are for Part D-covered drugs and the rules for drug coverage are followed:

  • The amount you pay for drugs when you are in any of the drug payment stages, including the deductible stage (if applicable to your plan)
  • Your copays and coinsurance during the initial coverage stage
  • What you spend on drugs stage and the amount of the manufacturer discount during the coverage gap
  • Any payments you made during the current calendar year under another Medicare prescription drug plan before joining a new plan

Payments for the above count towards your TrOOP costs if they are made by any of the following:

  • You
  • A friend, relative or certain charities on your behalf
  • AIDS Drug Assistance Programs
  • Indian Health Service
  • State Pharmaceutical Assistance Program (SPAP) qualified by Medicare
  • A Medicare Coverage Gap Discount Program (including what the drug manufacturer pays as part of the brand-name discount)
  • Medicare's Extra Help

In all cases, only payments for drugs your plan covers, including any "exceptions" you receive, count toward the TrOOP limit.

The following types of payments DO NOT count towards your TrOOP limit:

  • The amount you pay for your monthly premium
  • Drugs you buy outside the United States and its territories
  • Drugs that are not covered by our plan
  • Drugs you get at an out-of-network pharmacy that do not meet the plan's requirements for out-of-network coverage
  • Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from coverage by Medicare
  • Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan
  • Payments for your drugs that are made by group health plans including employer health plans.
  • Payments for your drugs that are made by insurance plans and government-funded health programs such as TRICARE and the Veteran's Administration.
  • Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Worker's Compensation).
How can I keep track of my out-of-pocket costs?

You will receive an Explanations of Benefits (EOB) statement from your Part D plan that includes the current amount of your out-of-pocket expenses along with other important information, such as what Part D Medicare stage (the deductible, initial coverage, gap coverage, and catastrophic coverage stages are described above) you are in. The EOB is sent to you on a monthly basis assuming you filled prescriptions in a given month.