The different stages of Medicare Part D coverage and understanding the Coverage Gap:
Your Medicare Part D plan benefit costs change throughout the year, so it’s important to understand what happens if you enter the Coverage Gap, also known as the Donut Hole. Review the four stages below to learn how costs other than your monthly premium may change.
The Annual Deductible Stage
You begin in the deductible stage when you fill your first prescription of the calendar year. During this stage, you pay the full cost of your drugs until the amount of your deductible has been reached. Then you move to the Initial Coverage stage. $0 deductible1 plans such as the SilverScript Choice, Plus2 and Allure2 plans start in the Initial Coverage stage. Some plans other than SilverScript charge as much as $415 in 2019 for a deductible.
The Initial Coverage Stage
This stage begins after you reach your deductible. If your plan does not have a deductible, this is the first stage of your benefit. During this stage cost sharing begins, which means you pay a copayment or coinsurance for prescription drugs until you reach your plan's initial coverage limit.
The Medicare Coverage Gap Stage
When you enter the Medicare Part D Coverage Gap stage, you have reached the Coverage Gap. This stage begins after your total drug costs have reached $3,820 in 2019. You exit the Coverage Gap stage when your total out-of-pocket costs (except for premiums) have reached $5,100 in 2019. Out-of-pocket costs include your annual deductible, as well as your copayments or coinsurance. The SilverScript Plus plan offers additional coverage for those who enter the Coverage Gap.
Some members, such as those who are part of the Extra Help program, do not enter the Coverage Gap.
The Catastrophic Coverage Stage
You enter this stage after your out-of-pocket costs have reached $5,100 in 2019. During this stage, you usually pay a low copayment or coinsurance for prescription drugs.
1In 2019, SilverScript Choice has a $100 deductible on Tier 3-5 drugs in CO, GA and TX; a $415 deductible on Tier 3-5 drugs in AZ and SC; and a $415 deductible on all tiers in AK. The Plus and Allure Plans are not available in Alaska in 2019.
2SilverScript Plus (PDP) and SilverScript Allure (PDP) are not available in Alaska.