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Medicare Coverage Gap

Most Part D plans have a temporary limit on what the plan will cover, also called the coverage gap or “donut hole".

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).

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 Health Management line at (713) 338-5353 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 healthcare 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.

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 OptumRx Home Delivery, you can save money versus using a retail pharmacy for your regular maintenance medications. Ask your physician to write for a 90 day supply for your regular maintenance medications. Keep in mind that pharmacies cannot dispense more than the quantity the prescriber wrote.

Preventive Drug List—In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions. Preventive medications are defined as those prescribed to prevent the occurrence of a chronic disease or condition for individuals with risk factors, or to prevent the recurrence of a disease or condition. Some eligible medications include those for high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, and heart disease.

To obtain prescription drugs by mail, use the following mail-order form or call our Pharmacy Member Services at (866) 909-5170 (TTY 711), Monday - Thursday, 24 hours a day, 7 days a week, Fridays from 12:00 a.m. to 9:00 p.m. CST, Saturdays from 7:00 a.m. to 3:30 p.m. CST, and Sundays from 9:00 p.m. to 12 a.m. CST.

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

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