Medicare Coverage Gap

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Medicare Coverage Gap

Tips for Navigating the Medicare Coverage Gap ("Donut Hole")

The Coverage Gap, also known as the “Donut Hole,” is part of the 4 official stages of Part D prescription coverage designed by the Center for Medicare and Medicaid Services (CMS). The coverage gap only begins after you and your plan have spent a certain amount for covered drugs after initial plan coverage limits have been reached and before catastrophic coverage kicks in. In the Coverage Gap, you pay a percentage of the drug cost until you reach your out-of-pocket limit for the year. Not everyone will enter the coverage gap.

Here are some ways to help manage drug costs before and during the Coverage Gap.

  1. Consult with your physician about using generic medications as these are usually much less expensive than brand medications. This will help keep your costs low and prolong entering the Coverage Gap.
  2. Read your monthly Explanation of Benefits (EOB) statement, which lists the prescriptions that you have filled in the previous month. It will show how much you have spent in copays/coinsurance, the total amount of your drug costs, and tracks progress toward the Coverage Gap or the next benefit stage.
  3. If you need help with your medications, call our Customer Service at (855) 645-8448 (TTY 711), 8 a.m. to 8 p.m. CT, 7 days a week from Oct. 1 – March 31 and 8 a.m. to 8 p.m. CT, Monday – Friday from April 1 – Sept. 30 to see if there are cost effective alternatives you could discuss with your physician, or patient assistant programs that you may qualify for.

How to save money on prescriptions

Tier 1 Generics—Many health plans implement the use of a Tier 1 Generic category on their formulary. These medications are recognized by the Food and Drug Administration (FDA) as having the same active ingredient and strength as their associated higher-priced brand drug. Consult with your physician to see if a Tier 1 Generic would work best for you.

90 Day Supply—Filling your prescription at your retail pharmacy for a 3 month supply instead of a month at a time could save you money, up to a month’s worth of copay! Also, it is convenient in regards to making fewer trips to the pharmacy–with a 90-day supply on-hand, you’re less likely to miss a dose.

Mail Order Pharmacy—The old saying “the more you buy, the more you save” may come to mind. By using the Mail Order Services through Costco Mail Order Pharmacy, you can save money, plus time versus using a retail pharmacy for your regular maintenance medications. Ask your physician to write a 90 day supply for your regular maintenance medications. Keep in mind that pharmacies cannot dispense more than the quantity the prescriber wrote.

Select Care Tier 6 Drugs—These medications are used to treat patients with diabetes, high cholesterol, and/or high blood pressure. These medications are available at a $0 copay at a preferred pharmacy for our members with these conditions.*

Pharmaceutical Assistance Programs—Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare prescription drug coverage (Part D). Find out whether there’s a Pharmaceutical Assistance Program that can lower prescription costs for the drugs you take. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website.)

State Pharmaceutical Assistance Programs—Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs. Find out if your state has a State Pharmaceutical Assistance Program. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website.)

Apply for Extra Help (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website.) - Medicare and Social Security have a program called Extra Help—a way for people with limited income and resources to get help with prescription costs. If you qualify for Extra Help, you could pay no more than:

  • $3.70 for each generic covered drug
  • $9.20 for each brand-name covered drug

To obtain prescription drugs by mail, use the links below or call our Pharmacy Member Services at (800) 607-6861 (TTY 711), Monday – Friday from 7 a.m. to 9 p.m. CT and Saturday – Sunday from 11:30 a.m. to 4 p.m. CT.

Mail Order Form – English
Mail Order Form – Spanish 

Prescription drugs that you get through any other mail-order service are not covered.

* Memorial Hermann Medicare Advantage HMO’s pharmacy network includes limited lower-cost, preferred pharmacies in current Texas service areas – Harris, Fort Bend and Montgomery counties. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call our Customer Service team at (855) 645-8448 (TTY 711).

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