Coverage Gap Tip Sheets | Answers4Families

CMS has prepared two tip sheets related to the coverage gap (sometimes called the "donut hole") that affects about 28% of people with Medicare who have drug coverage in a plan that has a coverage gap.

One tip sheet, "How the Coverage Gap works for People with Medicare Prescription Drug Plans," is a tip sheet for partners who work with people with Medicare and contains several questions and answers related to the coverage gap. That tip sheet is available at http://www.cms.hhs.gov/partnerships/downloads/PartneTipSheetExplCovGap080206.pdf

The second tip sheet, "Bridging the Coverage Gap," is written for distribution to people with Medicare and includes information on ways people can avoid or delay entering the gap, and continue to save money on drug costs while in the gap. That tip sheet is available at http://www.medicare.gov/Publications/Pubs/pdf/11213.pdf

One of the tips in the "Bridging the Coverage Gap" tip sheet is for people to look into Patient Assistance Programs that may be offered by manufacturers of drugs. SHIP counselors may find helpful a reference chart of Patient Assistance Programs prepared by the private organization RxAssist. That information is available at http://www.rxassist.org/docs/medicare-and-paps.cfm

Have You Reached the “Doughnut Hole” in Your Medicare Prescription Drug Plan?
Several Medicare prescription drug plans have a gap in coverage, sometimes referred to as a “doughnut hole.” In 2007, after you have accumulated $2,400 in total covered drug costs (what you and the plan have paid), you pay 100% of your covered drug costs until you have spent $3,850 out-of-pocket. After that, you will have “catastrophic coverage,” where you will pay only 5% of your covered drug costs for the rest of the calendar year.