Tips to Delay Reaching the Coverage Gap
What is the coverage gap? Is it the same as the donut hole?
Within the Medicare Part D prescription drug program, the donut hole is the phase of coverage during which all costs are paid by the member rather than by CMS. The term "coverage gap" is preferred by CMS and Prescription Drug Plans, but "donut hole" is commonly used.
Most plans have a donut hole. RxAmerica specializes in using generic drugs to keep members out of the coverage gap (donut hole). It is hard to predict when a member will reach the donut hole because there are a number of factors that determine when a member will reach this point in their coverage.
Compare the following charts to see how using generic prescriptions and over-the-counter (OTC) medications delay reaching the coverage gap. Craig used brand name medications only, while Merideth used generic and OTC medications when available.
Now, let's take a look at the examples...
Craig Example: Brand Medication Cost |
|||
|---|---|---|---|
| Medication | Initial Coverage per Month |
What counts toward the Coverage Gap | |
| Member pays | RxAmerica pays | ||
| Zocor tablet 40 mg 30 day supply |
$40 | $105.20 | $40 + $105.20 = $145.20 |
| Zoloft tablet 100 mg 30 day supply |
$40 | $45.19 | $40 + $45.19 = $85.19 |
| Nexium capsule 40mg 30 day supply |
$20 | $120.12 | $20 + $120.12 = $140.12 |
| Monthly total | $100 | $270.51 | $100 + $270.51 = $370.51 |
After meeting the deductible in month 1, in month 2 Craig would spend $100 out of pocket, but $370.51 would be applied toward his true out of pocket cost (TrOOP). At this rate Craig would reach the coverage gap in Month 7.
 Merideth Example: Generic and OTC Medication Cost |
|||
|---|---|---|---|
| Medication | Initial Coverage per Month |
What counts toward the Coverage Gap | |
| Member pays | RxAmerica pays | ||
| Simivastatin tablet 40mg 30 day supply (generic for Zocor) |
$5 | $7.23 | $5 + $7.23 = $12.23 |
| Sertraline hcl tablet 100mg 30 day supply (generic for Zoloft) |
$5 | $57.20 | $5 + $57.20 = $62.20 |
| Prilosec OTC 30 day supply |
$0 | $20 | $0* |
| Monthly total | $10 | $84.43 | $12.23 + $62.20 = $74.43 |
If you are currently using brand name medications, remember to talk to your doctor about generic and OTC* medications. Your doctor can help you decide if they are appropriate for you.
*Note: RxAmerica offers OTC medications as part of our Step Therapy (STC) program. The cost of OTC medications do not count toward the Coverage Gap or TrOOP.
