Medicare Part D Coverage Stages 

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Deductible Coverage Stage
There are no Senior Care Plus plans with this stage of coverage.
If there was a plan with this stage of coverage, the member would be responsible for 100% of the cost of their medications up to the annual deductible amount deemed by the Part D plan.
For Example: You are prescribed a medication that is covered by your Part D Plan at tier 2 (non-preferred generic) with a monthly cost of $110.00. You are responsible for 100% of the drug cost ($110.00). The amount of $110.00 is then counted toward meeting the annual deductible amount that has been set by your Part D plan. Once your deductible has been met you go into the Initial Coverage Stage.
 
Initial Coverage Stage
During the Initial Coverage Stage your plan will begin to cover the cost of your drugs up to your co-pay amount and these amounts are based on which plan you have chosen. Senior Care Plus offers a variety of plans to meet your initial coverage phase needs.
For example: You purchase a tier 3 (preferred brand) medication with a monthly retail cost of $747 per month. You pay your $47.00 co-pay and the plan pays $700 which is the remaining amount of the cost of the drug. Each time you have this medication filled the amount of $747.00 is going toward meeting the annual initial coverage stage limit of $4,130. The important thing to remember is this phase of coverage includes what the member pays combined with what the Part D plan pays. When the annual total drug costs paid by you and your Part D plan reach $4,130, you move into the Coverage Gap Stage.
 
Coverage Gap Stage (Donut Hole)
During the Coverage Gap Stage your Initial Coverage co-pays no longer apply because you’re total annual Initial Coverage drug spend has exceeded $4,130. During this phase, members will receive a 75% Donut Hole discount on the total cost of the brand and generic drugs purchased while in the donut hole. This discount includes a 70% discount paid by the brand-name drug manufacturer and a 5% discount paid by your Part D plan. The 70% paid by the drug manufacturer combined with the 25% you pay count toward your total out of pocket amount or Donut Hole exit point of $6,550.
For example: If you reach the Donut Hole and purchase a brand-name medication with a retail cost of $100, you will pay $25 for the medication, and receive $95 credit toward meeting your 2021 total out-of-pocket spending limit.
Medicare Part D beneficiaries who reach the Donut Hole will also pay a maximum of 25% co-pay on generic drugs purchased while in the Coverage Gap (receiving a 75% discount).
For example: If you reach the Donut Hole, and your generic medication has a retail cost of $100, you will pay $25. The $25 that you spend will count toward your total out of pocket amount or Donut Hole exit point of $6,550.
If your annual out-of-pocket reaches $6,550, you move into the Catastrophic Coverage Stage.
 
Catastrophic Coverage Stage
When your annual out-of-pocket costs exceed $6,550, you enter the Catastrophic Coverage Stage. Medicare beneficiaries will be charged $3.70 for those generic or preferred drugs with a retail price under $74.00 and 5% of the generic or preferred drug cost  for those with a retail price greater than $74.00. For brand-name drugs, beneficiaries would be charged $9.20 for those drugs with a retail price under $184 and 5% for those brand-name drugs with a retail price over $184.
For example: You purchase a generic or preferred drug with a retail price of $67.00. You will be charged $3.70 for it. Then the next month the same medication increases to a retail cost of $84.00, you would then be responsible for 5% of the cost leaving you with a copay of $4.20.
The same applies for brand name drug thresholds.
For example: You purchase a brand-name drug with a retail price of $172. You will be charged $9.20 for it. Then the next month you get the same medication filled and the retail price has increased the $192 you will be responsible for 5% of the cost leaving you with a copay of $9.60.
 
On January 1st of each year, your plan resets and the phases of coverage start over. It is important to keep track of which stage of coverage you are in throughout the year to help prepare you for the next stage of coverage where you may be responsible for a higher cost on your medications.

 

Senior Care Plus
A Medicare Advantage organization from Hometown Health