Prescription drugs are an important part of the treatment of long term medical conditions.  Considering the costs involved with some medications knowing what is covered and what isn’t can be critical to cost planning for healthcare.

The “Donut Hole”

Medicare Part D, responsible for prescription drug coverage, has a coverage gap.  This means that after a certain amount in benefits are paid out, coverage lapses until a second amount is reached.  Once this amount is reached then coverage begins again.  Here is how it works.

Each year there is a limit on what the drug plan will cover. This limit is based on the amount of money that is covered, not the amount that you pay out of pocket.  For example, if a drug you are taking costs $100 and you are responsible for only paying a $10 copay, the entire $100 goes towards the coverage limit.

Once you have reached that limit you are responsible to pay a certain percentage of the cost of the drugs; not your copay through your plan.  In 2015 this percentage is 45% of the full cost of the medication. Even at 45% of the cost, this can be very expensive.

There is an upper limit to the amount you must pay out of pocket.  Once your out of pocket expense is more than the upper limit, Medicare Part D will again pick up the majority of the costs.

For legal assistance with Medicare benefits, contact Stano Law group today.