Medicare Coverage Gap

The Medicare Part D prescription drug program consists of four stages: deductible, initial coverage, coverage gap and catastrophic coverage. Your cost for a drug depends on which stage you are in at the time you get your prescription filled or refilled. It is important to understand the coverage gap because you pay for a larger portion of your drug costs during this stage.

Please note: Some plans may have an annual Part D deductible. If you have a deductible, you will pay the full cost of your Part D medications until your plan deductible is met and you enter the Initial Coverage stage.

These amounts may change on January 1 of each year. This chart reflects dollar amounts for 2018.

You PAY Excellus BlueCross BlueShield PAYS Description
Initial Coverage Copayment or Coinsurance Remaining Cost
  • When you are in the Initial Coverage stage, you simply pay your copay or coinsurance for your covered medication. Excellus BlueCross BlueShield pays the rest of your medication costs.
  • You generally stay in this payment stage until the amount of your year-to-date total drug costs (what you pay plus what Excellus BlueCross BlueShield pays) reaches $3,750.
  • You will then enter what is called the "Coverage Gap."
Coverage Gap 35% of the cost for brand name medications and 44% of the cost for generic medications Partial cost for generic medications

When you are in the Coverage Gap, you receive limited coverage by Excellus BlueCross BlueShield and a discount on brand name medications.

  • You will pay 44% of the cost for all your covered generic medications. The 56% savings you receive for Generics does not count towards your true out-of-pocket costs.
  • You will pay only 35% at the pharmacy for your covered brand-name medications. The total cost of the medication (before the discount) applies toward your true out-of-pocket costs.
  • You generally stay in this stage until your true year-to-date out-of-pocket costs reach $5,000. You will then enter the Catastrophic Coverage stage.
Catastrophic Coverage 5% coinsurance or $3.35 (generic) or $8.35 (all other medications), whichever is greater Remaining cost
  • During this payment stage, you pay the greater of either 5% coinsurance or $3.35 generic; $8.35 for all other medications. Excellus BlueCross BlueShield pays most of the cost for your covered medications.
  • Once you are in this payment stage, you generally stay in it for the rest of the calendar year (through December 31).

How can you avoid reaching the coverage gap?

Using generic medications is the easiest way to avoid reaching the coverage gap. Generics have the lowest copay. Talk to your doctor and/or your pharmacist about using generics.

Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
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