People With Medicare

Medicare Question of the Month

Each month, our expert showcases a Medicare question submitted by one of our readers. You may submit a question at any time and get a personal response.

May 2012 Question:

I am in a Medicare Part D plan and have to take a lot of prescriptions. I think I am about to go into the coverage gap. How will I know if I do? And if I do, how will I afford my prescriptions?

Answer:

Each month that you fill any prescriptions using your Medicare Part D plan, you receive an Explanation of Benefit (EOB) summary in the mail. This summary shows the amount that you have paid for prescriptions drugs to date. It also shows how much your plan has paid to date. The EOB also shows you if you have reached the coverage gap for the year.

In 2012, you enter the coverage gap when your total cost - that is, what you spend plus what your Part D plan spends on prescriptions drugs - reaches a combined amount of $2,930. This amount changes each year.

If you do reach the coverage gap, you get a 50% discount on the cost of covered brand-name drugs and pay only 86% of the cost of covered generic drugs. You also pay a small dispensing fee associated with filling the prescriptions. Once drug costs reach $4,700 you would enter the catastrophic part of Medicare drug coverage, where you will remain for the rest of the year.

If you have the Extra Help/Low-Income Subsidy, you do not have a coverage gap.
Learn more about the coverage gap.

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