Understanding The Medicare Part D Coverage Gap
It’s important for KelseyCare Advantage members with Medicare prescription drug coverage to understand how the different stages of coverage work to prevent paying more than anticipated for your Part D drugs.
Your Part D coverage will assist with covering a certain portion of the negotiated drug cost depending on the stage of coverage which you are in during the prescription fill. The coverage stage will also affect the copay or coinsurance amount for which you are responsible.
Four Stages Of Coverage
|Deductible Stage||Tier 1 and 2 generic drugs are not subject to the deductible, and you will begin the benefit year paying initial coverage stage (stage 2) copays for these products. You will pay a yearly deductible of $100 on drugs placed on Tiers 3*, 4 and 5. You must pay the full cost of those drugs until you fulfill the plan deductible.|
|Initial Coverage Stage||Once the deductible for drugs placed on Tiers 3*, 4 and 5 is fulfilled, you will enter the Initial Coverage Stage and depending on the tier placement of your drugs, you will be responsible for a copay or coinsurance. Please refer to KelseyCare Advantage’s Formulary for further information about tier placement and cost sharing. You stay in this stage until your year-to-date “total drug costs” reach a total of $4,430. “Total Drug Costs” include what is paid by you and your insurance.|
|Coverage Gap ("Donut Hole")||In this stage, you will pay 25% of the negotiated drug cost for generic and brand medications placed in Tier 3*, 4 and 5. Copays for generic medications placed in Tier 1 and Tier 2 will remain the same as what you were responsible for during the deductible and initial coverage stages. Copays for Tier 3 Select Insulins will also remain the same as what you were responsible for during the deductible and initial coverage stages. Please refer to KelseyCare Advantage’s Formulary for further information regarding prescription medications and associated tiers. You will remain in the Coverage Gap Stage until your year-to-date “out-of-pocket costs” reach a total of $7,050.|
|Catastrophic Coverage Stage||You enter catastrophic coverage when your year-to-date “out-of-pocket costs” reach a total of $7,050. During Stage 4, KelseyCare Advantage pays most of the cost for your drugs.
Members who are not participating in the Medicare “Extra Help” program can expect to pay:
*Select Insulins on Tier 3 that are eligible for the Part D Senior Savings model will cost no more than $35 for a thirty-day supply during the deductible, initial coverage and coverage gap stages. This applies to certain plans only. For more information about the Part D Senior Savings Model refer to the 2022 Evidence of Coverage (EOC) or visit www.kelseycareadvantage.com.
**This article only applies to the City of Houston and TWU plans.