Department of Human Services

Q:    The Affordable Care Act Includes Benefits to Make Medicare Prescription Drug Coverage More Affordable During the Coverage Gap.  What are the New Benefits?

A:    When the Medicare Modernization Act legislation was written to include a prescription drug benefit in the Medicare program, a coverage gap was designed to alleviate some of the financial burden to the Medicare program. The Medicare program could not sustain paying for all prescription drugs for the more than 40+ million Medicare beneficiaries, especially with the ever-growing number of beneficiaries in the program each year. Most Medicare Prescription Drug plans (Part D) have a coverage gap. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay the full costs of your prescription drugs.

However, beginning in January of 2011 if you reach the coverage gap in your  Medicare Prescription Drug plan, you will get the following:

• A 50% discount on covered brand-name drugs when you buy them at a pharmacy or order them through the mail.
• Some coverage for generic drugs, and
• You can expect additional savings on your brand-name and generic drugs during the coverage gap over the next 10 years until it’s closed in 2020.

If a drug company has signed an agreement to participate in the Discount Program, all of the covered Part D brand-name drugs they make are covered during the coverage gap for that calendar year. This includes prescription drugs on the Part D plan’s formulary (list of covered drugs) and those covered through an appeal. In 2011, manufacturers that produce over 99% of the brand-name drugs used by people with Medicare are participating in this program.

Every month that you fill a prescription, your Medicare Part D drug plan mails you an Explanation of Benefits, (EOB) notice. Review your (EOB) notice to make sure that your prescription records are correct and up-to-date, and to find out if you received the brand-name drug discounts while in the coverage gap. If you don’t see the discount, work with your plan to make sure that you are in the coverage gap period, and that the brand name drug qualifies for the 50% discount. 

If you already get “Extra Help” from Medicare through the Low-income Subsidy program (LIS), then you will not get the 50% discount on brand-name drugs while in the coverage gap because you are already receiving assistance.

For more information about the closing of the coverage gap, call 1-800-Medicare, which is 1-800-633-4227, or visit www.medicare.gov . You can also contact your Medicare Prescription Drug plan. 

For information on Medicare’s “Extra-Help” program for Medicare beneficiaries with limited income and resources to help pay your prescription out-of-pocket drug costs, call 1-800-772-1213, which is the Social Security Administration (SSA). SSA determines eligibility for this program. You can also visit www.socialsecurity.gov to apply.