Know Your Plan: The Coverage Gap

What is the coverage gap?

The coverage gap (sometimes called the "donut hole") is when Medicare temporarily stops paying for your prescriptions and you have to pay the entire cost yourself. The coverage gap is only estimated to affect about 8% of Medicare beneficiaries and only applies to those who have Medicare prescription drug coverage. You may see little or no impact from the coverage gap if:

• You have very low drug costs each year.
• You have "extra help" (limited income subsidy) from Medicare or Social Security.
• You have Medicaid. (You may qualify for Medicaid part way through the year if your out-of-pocket spending on medicines or other healthcare significantly reduces the income you have left for living expenses.)
• You have coverage from a state program in addition to Medicare.
• You have an "enhanced" Medicare prescription drug plan or a Medicare Advantage Plan that provides extra coverage during the gap, possibly even eliminating it. You may switch to one of these plans during the next enrollment period (November 15 through December 31).

Some drug companies offer financial assistance for their medicines. To apply for these programs, visit www.HelpingPatients.org, www.RxAssist.org, or call the Partnership for Prescription Assistance at 1-888-477-2669.

All Medicare drug plans are not the same. When you join a Medicare drug plan, the plan sends you information about how the coverage gap works for that plan. Read this information carefully and call your plan if you have questions.

• Figure out if and when you will enter the coverage gap by reviewing the information you got when you signed up for your Medicare drug plan. Learn more about getting into and out of the coverage gap.
• Read and keep the monthly statements you get from your plan. These statements track how much you and your plan pay for your drugs each month. They also tell you how close you are to entering the coverage gap. It is also a good idea to keep track of your expenses yourself. Learn more about how to keep track of your spending for prescription drugs.

If you still have questions about your coverage:

• Call your plan.
• Call 1-800-MEDICARE (1-800-633-4227; TTY users should call 1-877-486-2048) or visit www.medicare.gov.
• Call Social Security to find out if you qualify for extra help; call 1-800-772-1213 (TTY users should call 1-800-325-0778).
• Call your local office on aging or visit www.eldercare.gov.
• Call your State Health Insurance Assistance Program for information about Medicare and Medicaid. To find one near you call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov.