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||
|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.
|Catastrophic Coverage||5% coinsurance or $3.35 (generic) or $8.35 (all other medications), whichever is greater||Remaining cost||
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.