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Do all Medicare part D drug plans have a coverage gap?

5 Answers

  • 1 decade ago
    Favorite Answer

    Medicare Part D plans--and the prescription drugs each plan covers--can be confusing. While not all Medicare Part D plans have a coverage gap, certainly most of them do. Some of the most expensive plans don't.

    One source of information is the the web site.

    If you would like some help in answering this question from real people--and how it will work if you need to change the Part D plan you have to another one to get the drugs you need--I would recommend that you contact the Area Agency on Aging where you live. You would want to have the listing of all the prescriptions you are taking, the dosages prescribed and also the pharmacy that you prefer to do business with. Professionals at the Area Agency on Aging can provide guidance in helping seniors and their caregivers deal with the peculiarities of the different Medicare Part D plans. You will most likely find the professional staff there friendly and helpful--and they are not selling any particular plan or product. They also know the latest "scoop" on changes that are still happening with Medicare Part D in your state. (Yes, even now more changes are happening within Medicare Part D plans!)

    If you live in the United States or one of the territories, there is an Area Agency on Aging serving where you live. You can call toll-free 1-800-677-1116 to find how to contact the one serving you.

    If you do contact your local Area Agency on Aging and like the help that they give you, let your local county officials and your folks in Congress know. Area Agencies on Aging are funded under the Older Americans Act and they don't have big budgets for advertising. Your contribution to help provide this important information and assistance to your older friends and neighbors would be appreciated--but is not necessary to get the help you are seeking.

    Good luck and best wishes!

    Source(s): National Association of Area Agencies on Aging
  • 5 years ago

    I've worked in Insurnce Administration for 12 years and was in on the ground floor when Medicare Part D was incepted. When a salesman says that a Medicare Part D plan doesn't have a Coverage Gap (or famously known as the Donut Hole), they are mistaken. In accordance with CMS/Medicare guidelines ALL (yes ALL) Medicare Part D plans are required to have a Donut Hole HOWEVER, there are specific types of plans that provide extra coverage through the Donut Hole. There are a couple different types, and they are often EGWP plans AKA Employer Group Waiver (sometimes called Wrap) Plans. These are very rich Medicare Part D plans that can be costly. There are some of these benefit rich plans available on the Individual market however, just like car insurance, you're gonna pay for it. For example, there are "GO" or Generic Only plans which means instead of the bare bones coverage that Medicare provides, the plan provides extra coverage for only Generics in the Donut Hole. Often the co-pay is the same in the Donut Hole as the Initial Coverage Stage (or Limit). Your EOB (Explanation of Benefits) is required by CMS/Medicare to indicate which stage you are in at any given time (usually by month). Some of the richer plans cover both your Generic and Brand Name drugs through the Donut Hole, so you could potentially pay very low co-pays (or co-pays that mirror your co-pays in the ICL) through the Donut Hole. The "Summary of Benefits" or EOC (Evidence of Coverage) or ANOC (Annual Notice of Change) and/or Cost Summary should list what your plans co-pays are through each stage. Side note: the phrase "Full Coverage" through the Donut Hole is also misleading. When someone says Full Coverage to someone, they can often think everything is paid for 100%, this is 99% of the time incorrect. Unless you purchase (or your employer provides) a plan that has $0 co-pays through all stages, you are not getting full coverage. This often means that the plan provides additional coverage (Wrap benefits) through the Donut Hole. To answer the 2nd above question, YES, a plan has the right to take drugs off the formulary at ANY TIME. In accordance with CMS/Medicare guidelines, any medication not approved by the FDA is not covered by a Medicare Part D plan. NOTE: Some employer or enhanced plans do cover Non-Medicare Part D drugs however you'll pay for it in premium... CMS/Medicare in conjunction with the PBM (Pharmacy Benefit Manager) and often "independent agencies", etc. will roll out a yearly formulary. Formularies are no means a full list of drugs covered, and often more expensive or higher Class drugs will need Prior Authorization, Step Therapy over-rides, and have Quantity Limit restrictions. Hope this helps!

  • ?
    Lv 4
    4 years ago

    decrease than the unique area D, while your total drug expenses (the expenses paid by skill of the two you and your plan) reached an preliminary cut back ($2,930 in 2012), your coverage might end thoroughly. The 2010 wellness care regulation did something with regard to the doughnut hollow. decrease than the regulation, the doughnut hollow progressively shrinks in line with annum until it disappears thoroughly by skill of 2020. The donut hollow is in all and sundry's area D drug plan.

  • 7 years ago

    can plans take drugs off covered list during the plan year

  • 6 years ago

    which plans do not have a coverage gap?

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