Medicare Coverage Gap
Tips for Navigating the Medicare Coverage Gap ("Donut Hole")
The Coverage Gap, also known as the “Donut Hole,” is part of the four official stages of Part D prescription coverage designed by the Center for Medicare and Medicaid Services (CMS). The coverage gap only begins after you and your plan have spent a certain amount for covered drugs after initial plan coverage limits have been reached and before catastrophic coverage kicks in. In the Coverage Gap, you pay a percentage of the drug cost until you reach your out-of-pocket limit for the year. Not everyone will enter the coverage gap.
Here are some ways to help manage drug costs before and during the Coverage Gap.
- Consult with your physician about using generic medications as these are usually much less expensive than brand medications. This will help keep your costs low and prolong entering the Coverage Gap.
- 2. Consider using medications listed on our formulary as Tier 6 - Select Care Drugs. This is a $0 co-pay tier with medications commonly prescribed to treat ongoing health conditions like high blood pressure, cholesterol, and diabetes when purchased at a preferred pharmacy.
- Read your monthly Explanation of Benefits (EOB) statement, which lists the prescriptions that you have filled in the previous month. It will show how much you have spent in copays/coinsurance, the total amount of your drug costs, and tracks progress toward the Coverage Gap or the next benefit stage.
- If you need help with your medications, call our Customer Service at (855) 645-8448 (TTY 711), 8 a.m. to 8 p.m. CT, 7 days a week from Oct. 1 – March 31 and 8 a.m. to 8 p.m. CT, Monday – Friday from April 1 – Sept. 30 to see if there are cost effective alternatives you could discuss with your physician, or patient assistant programs that you may qualify for.
How to save money on prescriptions
Tier 1 Generics—Many health plans implement the use of a Tier 1 Generic category on their formulary. These medications are recognized by the Food and Drug Administration (FDA) as having the same active ingredient and strength as their associated higher-priced brand drug. Consult with your physician to see if a Tier 1 Generic would work best for you.
90 Day Supply—Filling your prescription at your retail pharmacy for a 3 month supply instead of a month at a time could save you money, up to a month’s worth of copay! Also, it is convenient, in regards to making fewer trips to the pharmacy. With a 90-day supply on-hand, you’re less likely to miss a dose.
Use a Preferred Pharmacy—Our pharmacy network includes limited lower-cost, preferred pharmacies in current Texas service areas. Please review the pharmacy directory to view the most updated information on which pharmacies may be preferred.
The lower costs advertised in our plan materials are only available at a preferred pharmacy. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call our Customer Service team at (855) 645-8448 (TTY 711).
Mail Order Pharmacy—The old saying “the more you buy, the more you save” may come to mind. By using the Mail Order Services through Costco® Mail Order Pharmacy, you can save money, plus time versus using a retail pharmacy for your regular maintenance medications. Ask your physician to write a 90 day supply for your regular maintenance medications. Keep in mind that pharmacies cannot dispense more than the quantity the prescriber wrote.
To obtain prescription drugs by mail, use the links below or call our Pharmacy Customer Service at (800) 607-6861 (TTY 711), Monday – Friday from 7 a.m. to 9 p.m. CT and Saturday – Sunday from 11:30 a.m. to 4 p.m. CT.
Costco Mail Order Pharmacy Form – English
Costco Mail Order Pharmacy Form – Spanish
Prescription drugs that you get through any other mail-order service are not covered.
Select Care Tier 6 Drugs—These medications are used to treat patients with diabetes, high cholesterol, and/or high blood pressure. These medications are available at a $0 copay at a preferred pharmacy for our members with these conditions.*
Select Insulin (SI)—The insulins in this category are limited insulin products that are selected as part of the CMS Senior Savings Model program at a reduced member copay. You pay a $35.00 copay for Select Insulins (SI) at Preferred or Standard pharmacies for a 30-day supply (including through the Coverage Gap). To find out which drugs are Select Insulins, review the most recent Drug List or formulary. You can identify Select Insulins by SI symbol in the Drug List. If you have questions about the Drug List, you can also call Customer Service at (855) 645-8448. If you receive Low-Income cost-sharing Subsidy (LIS), sometimes called Extra Help, you already have a set co-payment and are not eligible for the savings on Select Insulins (SI) co-payments. Only, non-LIS enrollees are eligible for the cost sharing for Select Insulins (SI). If you have questions about the copayment for Select Insulins (SI), you can also call Customer Service at (855) 645-8448.
Pharmaceutical Assistance Programs—Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare prescription drug coverage (Part D). Find out whether there’s a Pharmaceutical Assistance Program that can lower prescription costs for the drugs you take. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website.)
State Pharmaceutical Assistance Programs—Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs. Find out if your state has a State Pharmaceutical Assistance Program. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website.)
Apply for Extra Help (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website.) - Medicare and Social Security have a program called Extra Help—a way for people with limited income and resources to get help with prescription costs. If you qualify for Extra Help, you could pay no more than:
- $4.15 for each generic covered drug
- $10.35 for each brand-name covered drug
*Memorial Hermann Medicare Advantage HMO’s pharmacy network includes limited lower-cost, preferred pharmacies in current Texas service areas. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call our Customer Service team at (855) 645-8448 (TTY 711) or visit the pharmacy directory page.