Tips to Delay Reaching the Coverage Gap
What is the coverage gap? Is it the same as the donut hole? Or doughnut hole?
"Within the Medicare Part D prescription drug program, the Donut Hole (or Doughnut Hole) is the phase of coverage in which all costs are covered by the enrollee rather than CMS. The term "coverage gap" is preferred by CMS and Prescription Drug Plans, but Donut Hole has been more widely adopted in the popular media." http://en.wikipedia.org/wiki/Donut_Hole
As stated above, the donut hole and coverage gap are one in the same. The donut hole is a time when all prescription drug costs are paid by the member. All programs; nationwide, 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. Zhang used brand name medications only, while Merideth used Generic and OTC medication when available.
Now, let's take a look at the examples...
 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.
