PTC-008R10

Monthly Expenses for Covered Drugs
Mary Paid: Plan Paid: Total Drug Cost:
January $360.00 $360.00 $720.00
February $180.00 $540.00 $720.00
March $180.00 $540.00 $720.00
April $230.00 $490.00 $720.00
Total expenses from
January to April
$950.00 $1,930.00 $2,880.00
May $720.00 $0 $720.00
June $720.00 $0 $720.00
July $720.00 $0 $720.00
August $720.00 $0 $720.00
September $720.00 $0 $720.00
Total expenses from
January to September
$4,550.00 $1,930.00 $6,480.00
October $36.00 $684.00 $720.00
November $36.00 $684.00 $720.00
December $36.00 $684.00 $720.00
You can find out how much your plan paid by looking at your pharmacy receipt.
• The amount you paid plus the amount your plan paid is your total drug cost. Add your total drug costs
each month to see how close you are to entering the coverage gap. Remember, in 2010 you enter the
coverage gap when your total drug costs reach $2,830.
• Add the total amounts you paid each month to find out how close you are to exiting the coverage
gap. In 2010, the out-of-pocket limit for most plans that have a coverage gap is $4,550.
Mary paid more in
January because she
had to meet her $310
deductible before her
plan started to pay
toward the cost of her
medicines.
Mary entered the
coverage gap in April
because her total drug
costs (what she paid
plus what her plan
paid) reached $2,830.
Mary exited the
coverage gap at the
end of September
because the total
amount that she
paid herself for her
medicines reached
$4,550.
In October, Mary
entered “catastrophic
coverage.” She paid
5% of the cost for her
medicines and her
plan paid the rest.
Sample Expense Log
It’s important to track your spending to see when you will enter and exit the coverage gap. The
sample Expense Log below shows you how.
Mary has Medicare prescription drug coverage for the seven medicines she takes every month. Her
plan has a $310 deductible at the beginning of the year and Mary pays a copay for each of her
prescriptions. Your plan may be different than Mary’s.
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Resources for Medicare Beneficiaries:
Navigating the Coverage Gap
YourPharmacyBenef|t.org
1894 Preston Wh|te Dr|ve
Reston, vA 20191
How the Gap May Affect You
www.Yvu·1¡u·mu.,BeneJ.:.v·g
Resources for Medicare Beneficiaries:
Navigating the Coverage Gap
How the Gap May Affect You
What is the Coverage Gap?
The coverage gap (somet|mes ca||ed the 'donut ho|e"} |s when Med|care temporar||y stops pay|ng
for your prescr|pt|ons and you have to pay the ent|re cost yourse|f. The coverage gap
prescr|pt|on drug coverage. You may see ||tt|e or no |mpact from the coverage gap |f:
º You have very |ow drug costs each year.
º You have 'extra he|p" (||m|ted |ncome subs|dy} from Med|care or the Soc|a| Secur|ty
Adm|n|strat|on.
º You have Med|ca|d. (You may qua||fy for Med|ca|d part way through the year |f your out-of-
pocket spend|ng on med|c|nes or other hea|th care s|gn|f|cant|y reduces the |ncome you have
|eft for ||v|ng expenses.}
º You have coverage from a state program |n add|t|on to Med|care.
º You have an 'enhanced" Med|care prescr|pt|on drug p|an or a Med|care Advantage P|an that
prov|des extra coverage dur|ng the gap, poss|b|y even e||m|nat|ng |t. You may sw|tch to one of
these p|ans dur|ng the next enro||ment per|od (genera||y November 15 through December 31,
Some drug compan|es offer f|nanc|a| ass|stance for the|r med|c|nes. To app|y for these programs, v|s|t
www.he|p|ngpat|ents.org or ca|| the Partnersh|p for Prescr|pt|on Ass|stance at 1-888-477-2669.
lf you th|nk you may be affected by the coverage gap, read on to f|nd out more about how |t works.
each year}.
the major|ty of Med|care benef|c|ar|es and on|y app||es to those who have Med|care
does not
affect
8/2010
PIanning Ahead: How the Coverage Gap May Affect You
A|| Med|care drug p|ans are not the same. When you jo|n a Med|care drug p|an, the
p|an sends you |nformat|on about how the coverage gap works for that p|an. Read
th|s |nformat|on carefu||y and ca|| your p|an |f you have quest|ons.
º F|gure out |f and when you w||| enter the coverage gap by rev|ew|ng the
|nformat|on you got when you s|gned up for your Med|care drug p|an.
º Read and keep the month|y statements you get from your p|an. These statements
track how much you and your p|an pay for your drugs each month. They a|so te||
you how c|ose you are to enter|ng the coverage gap. lt |s a|so a good |dea to
keep track of your expenses yourse|f. Pages 4 and 5 exp|a|n how.
lf you st||| have quest|ons about your coverage, ca|| your p|an. YYY
800-MEDlOARE (1-800-633-4227}; TTY users shou|d ca|| 1-877-486-2048.
The Ü.S. Department of Hea|th and Human Serv|ces' Oenters for Med|care & Med|ca|d Serv|ces has
rev|ewed th|s pub||cat|on, wh|ch |s pr rr oduced by YourPharmacyBenef|t.org. YourPharmacyBenef|t.org |s rr
a co||aborat|ve effort among non-pr ff of|t organ|zat|ons represent|ng consumers, phys|c|ans, pharmacy,
and pharmaceut|ca| compan|es that str|ves to educate consumers to make |nformed dec|s|ons when
choos|ng and us|ng the|r pharmacy benef|ts, thus empower|ng them to access the med|c|nes the|r
hea|th care prov|ders prescr|be. Th|s pub||cat|on may be repr|nted for educat|ona| and nonprof|t
purposes.
To TT request add|t|ona| cop|es of th|s book|et, wr|te to:
Federa| O|t|zen lnformat|on Oenter
Pueb|o, OO 81009
or go to www.pueb|o.gsa.gov
Yo0 may be ab|e to de|ay reach|og the coverage YY
gap by 0s|og |ower-cost dr0gs covered by yo0r
p|ao, check w|th yo0r hea|th care prov|der to
see |I there are other med|c|oes that w||| work
Ior yo0.

ou can a|so ca|| 1-

|t's |mportaot to keep tak|og yo0r med|c|oes as
prescr|bed d0r|og the coverage gap. Yo0 sho0|d oever
make chaoges ||ke sk|pp|og doses, c0tt|og p|||s |o ha|I, or
stopp|og a med|cat|oo w|tho0t I|rst ta|k|og to yo0r hea|th
are prov|der.
|I yo0 have h|gh tota| dr0g costs aod doo't have
extra he|p d0r|og the coverage gap, coos|der
sw|tch|og to a p|ao that doeso't have a coverage
gap. Yo YY 0 cao sw|tch p|aos betweeo
hovember 15 aod 0ecember 31 . |I
yo0 sw|tch p|aos d0r|og th|s t|me, yo0r oew
coverage w||| start Jao0ar .

Keeping Track of Your Spending
You shou|d a|ways show your Med|care card at the pharmacy when you f||| a
prescr|pt|on, even |f you don`t th|nk the p|an w||| pay anyth|ng. lt |s a|so |mportant to
keep track of your spend|ng for covered drugs so you know when you are com|ng
c|ose to enter|ng and ex|t|ng the coverage gap.
º Ask your pharmac|st to te|| you |f your p|an covers your med|cat|on when you f|||
the prescr|pt|on. Make a note on the rece|pt to rem|nd you what the pharmac|st
to|d you.
º Save a|| your rece|pts for prescr|pt|on med|c|nes.
º Read and keep a|| month|y statements from your p|an.
º Keep an Expense |og to track your month|y costs. The samp|e on page 5 shows
you how.
º Oa|| your p|an |f you have quest|ons about your expenses.
Getting HeIp During the Gap
º Soc|a| Secur|ty can te|| you |f you qua||fy for extra
he|p; ca|| 1-800-772-1213 (TTY users shou|d ca|| 1-
800-325-0778}.
º Oa|| your |oca| off|ce on ag|ng or v|s|t www ff .e|dercar rr e.gov rr .
º Oa|| your State Hea|th lnsurance Ass|stance Program
for |nformat|on about Med|care and Med|ca|d. To TT f|nd
one near you ca|| 1-800-MEDlOARE (1-800-633-
4227} or v|s|t www.med|care.gov.
geoera||y
y the Io||ow|og
each year
Publication Title - Medicare Beneficiaries: Navigating the Coverage Gap

Getting Into and Out of the Coverage Gap: How It Works
In a standard Medicare drug plan in 2010, you enter the coverage gap when the total
amount spent on “covered drugs” by you and your plan combined reaches $2,830.
One covered drugs count toward getting you into – and out of – the coverage gap.
Covered drugs are medicines for which your plan pays at least part of the cost at some
time during the year.
• Once you enter the coverage gap, you must pay 100% of your prescription dug
costs until the total amount you have paid reaches the “out-of-pocket limit.” The out-
of-pocket limit is a dollar amount hat marks the end of the coverage gap. This limit
includes the amounts you paid before you entered the coverage gap. In 2010, the out-
of-pocket limit for most plans that have a coverage gap is $4,550.
• Once you reach the out-of-pocket limit you pay a small copayment or coinsurance for
your medicines until the end of the calendar year. Your plan pays the rest. This is called
“catastrophic” coverage because it protects you if your total drug costs are very high.
Only certain kinds of expenses count toward the out-of-pocket limit.
• Expenses that count toward the out-of-pocket limit include what you spend on covered
drugs (including your deductible, copayments, coinsurance, and all payments you
make for covered drugs through the coverage gap).
• Expenses that do not count toward the out-of-pocket limit include your monthly
premium payments, payments for drugs that are not covered drugs, payments for
drugs purchased from other countries such as Canada, and costs paid by certain
assistance programs.
• The Affordable Care Act passed by Congress and signed by President Obama in
2010 contains some important benefits for Medicare recipients with prescription drug
coverage who reach the coverage gap. If you aren’t already getting Medicare Extra
Help, Medicare will automatically send you a tax free, one-time $250 rebate check after
you reach the coverage gap (also called the “donut hole”) in 2010. This rebate is the
first step toward closing the Medicare prescription drug coverage gap.
• If you reach the coverage gap in 2011 and are not getting Medicare Extra Help, you will
receive a 50% discount on any brand prescription you purchase while you are in the
coverage gap. Additional help is planned for future years.
PIanning Ahead: How the Coverage Gap May Affect You
A|| Med|care drug p|ans are not the same. When you jo|n a Med|care drug p|an, the
p|an sends you |nformat|on about how the coverage gap works for that p|an. Read
th|s |nformat|on carefu||y and ca|| your p|an |f you have quest|ons.
º F|gure out |f and when you w||| enter the coverage gap by rev|ew|ng the
|nformat|on you got when you s|gned up for your Med|care drug p|an.
º Read and keep the month|y statements you get from your p|an. These statements
track how much you and your p|an pay for your drugs each month. They a|so te||
you how c|ose you are to enter|ng the coverage gap. lt |s a|so a good |dea to
keep track of your expenses yourse|f. Pages 4 and 5 exp|a|n how.
lf you st||| have quest|ons about your coverage, ca|| your p|an. YYY
800-MEDlOARE (1-800-633-4227}; TTY users shou|d ca|| 1-877-486-2048.
The Ü.S. Department of Hea|th and Human Serv|ces' Oenters for Med|care & Med|ca|d Serv|ces has
rev|ewed th|s pub||cat|on, wh|ch |s pr rr oduced by YourPharmacyBenef|t.org. YourPharmacyBenef|t.org |s rr
a co||aborat|ve effort among non-pr ff of|t organ|zat|ons represent|ng consumers, phys|c|ans, pharmacy,
and pharmaceut|ca| compan|es that str|ves to educate consumers to make |nformed dec|s|ons when
choos|ng and us|ng the|r pharmacy benef|ts, thus empower|ng them to access the med|c|nes the|r
hea|th care prov|ders prescr|be. Th|s pub||cat|on may be repr|nted for educat|ona| and nonprof|t
purposes.
To TT request add|t|ona| cop|es of th|s book|et, wr|te to:
Federa| O|t|zen lnformat|on Oenter
Pueb|o, OO 81009
or go to www.pueb|o.gsa.gov
Yo0 may be ab|e to de|ay reach|og the coverage YY
gap by 0s|og |ower-cost dr0gs covered by yo0r
p|ao, check w|th yo0r hea|th care prov|der to
see |I there are other med|c|oes that w||| work
Ior yo0.

ou can a|so ca|| 1-

|t's |mportaot to keep tak|og yo0r med|c|oes as
prescr|bed d0r|og the coverage gap. Yo0 sho0|d oever
make chaoges ||ke sk|pp|og doses, c0tt|og p|||s |o ha|I, or
stopp|og a med|cat|oo w|tho0t I|rst ta|k|og to yo0r hea|th
are prov|der.
|I yo0 have h|gh tota| dr0g costs aod doo't have
extra he|p d0r|og the coverage gap, coos|der
sw|tch|og to a p|ao that doeso't have a coverage
gap. Yo YY 0 cao sw|tch p|aos betweeo
hovember 15 aod 0ecember 31 . |I
yo0 sw|tch p|aos d0r|og th|s t|me, yo0r oew
coverage w||| start Jao0ar .

Keeping Track of Your Spending
You shou|d a|ways show your Med|care card at the pharmacy when you f||| a
prescr|pt|on, even |f you don`t th|nk the p|an w||| pay anyth|ng. lt |s a|so |mportant to
keep track of your spend|ng for covered drugs so you know when you are com|ng
c|ose to enter|ng and ex|t|ng the coverage gap.
º Ask your pharmac|st to te|| you |f your p|an covers your med|cat|on when you f|||
the prescr|pt|on. Make a note on the rece|pt to rem|nd you what the pharmac|st
to|d you.
º Save a|| your rece|pts for prescr|pt|on med|c|nes.
º Read and keep a|| month|y statements from your p|an.
º Keep an Expense |og to track your month|y costs. The samp|e on page 5 shows
you how.
º Oa|| your p|an |f you have quest|ons about your expenses.
Getting HeIp During the Gap
º Soc|a| Secur|ty can te|| you |f you qua||fy for extra
he|p; ca|| 1-800-772-1213 (TTY users shou|d ca|| 1-
800-325-0778}.
º Oa|| your |oca| off|ce on ag|ng or v|s|t www ff .e|dercar rr e.gov rr .
º Oa|| your State Hea|th lnsurance Ass|stance Program
for |nformat|on about Med|care and Med|ca|d. To TT f|nd
one near you ca|| 1-800-MEDlOARE (1-800-633-
4227} or v|s|t www.med|care.gov.
geoera||y
y the Io||ow|og
each year
Publication Title - Medicare Beneficiaries: Navigating the Coverage Gap

Getting Into and Out of the Coverage Gap: How It Works
In a standard Medicare drug plan in 2010, you enter the coverage gap when the total
amount spent on “covered drugs” by you and your plan combined reaches $2,830.
One covered drugs count toward getting you into – and out of – the coverage gap.
Covered drugs are medicines for which your plan pays at least part of the cost at some
time during the year.
• Once you enter the coverage gap, you must pay 100% of your prescription dug
costs until the total amount you have paid reaches the “out-of-pocket limit.” The out-
of-pocket limit is a dollar amount hat marks the end of the coverage gap. This limit
includes the amounts you paid before you entered the coverage gap. In 2010, the out-
of-pocket limit for most plans that have a coverage gap is $4,550.
• Once you reach the out-of-pocket limit you pay a small copayment or coinsurance for
your medicines until the end of the calendar year. Your plan pays the rest. This is called
“catastrophic” coverage because it protects you if your total drug costs are very high.
Only certain kinds of expenses count toward the out-of-pocket limit.
• Expenses that count toward the out-of-pocket limit include what you spend on covered
drugs (including your deductible, copayments, coinsurance, and all payments you
make for covered drugs through the coverage gap).
• Expenses that do not count toward the out-of-pocket limit include your monthly
premium payments, payments for drugs that are not covered drugs, payments for
drugs purchased from other countries such as Canada, and costs paid by certain
assistance programs.
• The Affordable Care Act passed by Congress and signed by President Obama in
2010 contains some important benefits for Medicare recipients with prescription drug
coverage who reach the coverage gap. If you aren’t already getting Medicare Extra
Help, Medicare will automatically send you a tax free, one-time $250 rebate check after
you reach the coverage gap (also called the “donut hole”) in 2010. This rebate is the
first step toward closing the Medicare prescription drug coverage gap.
• If you reach the coverage gap in 2011 and are not getting Medicare Extra Help, you will
receive a 50% discount on any brand prescription you purchase while you are in the
coverage gap. Additional help is planned for future years.
PIanning Ahead: How the Coverage Gap May Affect You
A|| Med|care drug p|ans are not the same. When you jo|n a Med|care drug p|an, the
p|an sends you |nformat|on about how the coverage gap works for that p|an. Read
th|s |nformat|on carefu||y and ca|| your p|an |f you have quest|ons.
º F|gure out |f and when you w||| enter the coverage gap by rev|ew|ng the
|nformat|on you got when you s|gned up for your Med|care drug p|an.
º Read and keep the month|y statements you get from your p|an. These statements
track how much you and your p|an pay for your drugs each month. They a|so te||
you how c|ose you are to enter|ng the coverage gap. lt |s a|so a good |dea to
keep track of your expenses yourse|f. Pages 4 and 5 exp|a|n how.
lf you st||| have quest|ons about your coverage, ca|| your p|an. YYY
800-MEDlOARE (1-800-633-4227}; TTY users shou|d ca|| 1-877-486-2048.
The Ü.S. Department of Hea|th and Human Serv|ces' Oenters for Med|care & Med|ca|d Serv|ces has
rev|ewed th|s pub||cat|on, wh|ch |s pr rr oduced by YourPharmacyBenef|t.org. YourPharmacyBenef|t.org |s rr
a co||aborat|ve effort among non-pr ff of|t organ|zat|ons represent|ng consumers, phys|c|ans, pharmacy,
and pharmaceut|ca| compan|es that str|ves to educate consumers to make |nformed dec|s|ons when
choos|ng and us|ng the|r pharmacy benef|ts, thus empower|ng them to access the med|c|nes the|r
hea|th care prov|ders prescr|be. Th|s pub||cat|on may be repr|nted for educat|ona| and nonprof|t
purposes.
To TT request add|t|ona| cop|es of th|s book|et, wr|te to:
Federa| O|t|zen lnformat|on Oenter
Pueb|o, OO 81009
or go to www.pueb|o.gsa.gov
Yo0 may be ab|e to de|ay reach|og the coverage YY
gap by 0s|og |ower-cost dr0gs covered by yo0r
p|ao, check w|th yo0r hea|th care prov|der to
see |I there are other med|c|oes that w||| work
Ior yo0.

ou can a|so ca|| 1-

|t's |mportaot to keep tak|og yo0r med|c|oes as
prescr|bed d0r|og the coverage gap. Yo0 sho0|d oever
make chaoges ||ke sk|pp|og doses, c0tt|og p|||s |o ha|I, or
stopp|og a med|cat|oo w|tho0t I|rst ta|k|og to yo0r hea|th
are prov|der.
|I yo0 have h|gh tota| dr0g costs aod doo't have
extra he|p d0r|og the coverage gap, coos|der
sw|tch|og to a p|ao that doeso't have a coverage
gap. Yo YY 0 cao sw|tch p|aos betweeo
hovember 15 aod 0ecember 31 . |I
yo0 sw|tch p|aos d0r|og th|s t|me, yo0r oew
coverage w||| start Jao0ar .

Keeping Track of Your Spending
You shou|d a|ways show your Med|care card at the pharmacy when you f||| a
prescr|pt|on, even |f you don`t th|nk the p|an w||| pay anyth|ng. lt |s a|so |mportant to
keep track of your spend|ng for covered drugs so you know when you are com|ng
c|ose to enter|ng and ex|t|ng the coverage gap.
º Ask your pharmac|st to te|| you |f your p|an covers your med|cat|on when you f|||
the prescr|pt|on. Make a note on the rece|pt to rem|nd you what the pharmac|st
to|d you.
º Save a|| your rece|pts for prescr|pt|on med|c|nes.
º Read and keep a|| month|y statements from your p|an.
º Keep an Expense |og to track your month|y costs. The samp|e on page 5 shows
you how.
º Oa|| your p|an |f you have quest|ons about your expenses.
Getting HeIp During the Gap
º Soc|a| Secur|ty can te|| you |f you qua||fy for extra
he|p; ca|| 1-800-772-1213 (TTY users shou|d ca|| 1-
800-325-0778}.
º Oa|| your |oca| off|ce on ag|ng or v|s|t www ff .e|dercar rr e.gov rr .
º Oa|| your State Hea|th lnsurance Ass|stance Program
for |nformat|on about Med|care and Med|ca|d. To TT f|nd
one near you ca|| 1-800-MEDlOARE (1-800-633-
4227} or v|s|t www.med|care.gov.
geoera||y
y the Io||ow|og
each year
Publication Title - Medicare Beneficiaries: Navigating the Coverage Gap

Getting Into and Out of the Coverage Gap: How It Works
In a standard Medicare drug plan in 2010, you enter the coverage gap when the total
amount spent on “covered drugs” by you and your plan combined reaches $2,830.
One covered drugs count toward getting you into – and out of – the coverage gap.
Covered drugs are medicines for which your plan pays at least part of the cost at some
time during the year.
• Once you enter the coverage gap, you must pay 100% of your prescription dug
costs until the total amount you have paid reaches the “out-of-pocket limit.” The out-
of-pocket limit is a dollar amount hat marks the end of the coverage gap. This limit
includes the amounts you paid before you entered the coverage gap. In 2010, the out-
of-pocket limit for most plans that have a coverage gap is $4,550.
• Once you reach the out-of-pocket limit you pay a small copayment or coinsurance for
your medicines until the end of the calendar year. Your plan pays the rest. This is called
“catastrophic” coverage because it protects you if your total drug costs are very high.
Only certain kinds of expenses count toward the out-of-pocket limit.
• Expenses that count toward the out-of-pocket limit include what you spend on covered
drugs (including your deductible, copayments, coinsurance, and all payments you
make for covered drugs through the coverage gap).
• Expenses that do not count toward the out-of-pocket limit include your monthly
premium payments, payments for drugs that are not covered drugs, payments for
drugs purchased from other countries such as Canada, and costs paid by certain
assistance programs.
• The Affordable Care Act passed by Congress and signed by President Obama in
2010 contains some important benefits for Medicare recipients with prescription drug
coverage who reach the coverage gap. If you aren’t already getting Medicare Extra
Help, Medicare will automatically send you a tax free, one-time $250 rebate check after
you reach the coverage gap (also called the “donut hole”) in 2010. This rebate is the
first step toward closing the Medicare prescription drug coverage gap.
• If you reach the coverage gap in 2011 and are not getting Medicare Extra Help, you will
receive a 50% discount on any brand prescription you purchase while you are in the
coverage gap. Additional help is planned for future years.
PTC-008R10
Monthly Expenses for Covered Drugs
Mary Paid: Plan Paid: Total Drug Cost:
January $360.00 $360.00 $720.00
February $180.00 $540.00 $720.00
March $180.00 $540.00 $720.00
April $230.00 $490.00 $720.00
Total expenses from
January to April
$950.00 $1,930.00 $2,880.00
May $720.00 $0 $720.00
June $720.00 $0 $720.00
July $720.00 $0 $720.00
August $720.00 $0 $720.00
September $720.00 $0 $720.00
Total expenses from
January to September
$4,550.00 $1,930.00 $6,480.00
October $36.00 $684.00 $720.00
November $36.00 $684.00 $720.00
December $36.00 $684.00 $720.00
You can find out how much your plan paid by looking at your pharmacy receipt.
• The amount you paid plus the amount your plan paid is your total drug cost. Add your total drug costs
each month to see how close you are to entering the coverage gap. Remember, in 2010 you enter the
coverage gap when your total drug costs reach $2,830.
• Add the total amounts you paid each month to find out how close you are to exiting the coverage
gap. In 2010, the out-of-pocket limit for most plans that have a coverage gap is $4,550.
Mary paid more in
January because she
had to meet her $310
deductible before her
plan started to pay
toward the cost of her
medicines.
Mary entered the
coverage gap in April
because her total drug
costs (what she paid
plus what her plan
paid) reached $2,830.
Mary exited the
coverage gap at the
end of September
because the total
amount that she
paid herself for her
medicines reached
$4,550.
In October, Mary
entered “catastrophic
coverage.” She paid
5% of the cost for her
medicines and her
plan paid the rest.
Sample Expense Log
It’s important to track your spending to see when you will enter and exit the coverage gap. The
sample Expense Log below shows you how.
Mary has Medicare prescription drug coverage for the seven medicines she takes every month. Her
plan has a $310 deductible at the beginning of the year and Mary pays a copay for each of her
prescriptions. Your plan may be different than Mary’s.
ä
ä
ä
ä

Resources for Medicare Beneficiaries:
Navigating the Coverage Gap
YourPharmacyBenef|t.org
1894 Preston Wh|te Dr|ve
Reston, vA 20191
How the Gap May Affect You
www.Yvu·1¡u·mu.,BeneJ.:.v·g
Resources for Medicare Beneficiaries:
Navigating the Coverage Gap
How the Gap May Affect You
What is the Coverage Gap?
The coverage gap (somet|mes ca||ed the 'donut ho|e"} |s when Med|care temporar||y stops pay|ng
for your prescr|pt|ons and you have to pay the ent|re cost yourse|f. The coverage gap
prescr|pt|on drug coverage. You may see ||tt|e or no |mpact from the coverage gap |f:
º You have very |ow drug costs each year.
º You have 'extra he|p" (||m|ted |ncome subs|dy} from Med|care or the Soc|a| Secur|ty
Adm|n|strat|on.
º You have Med|ca|d. (You may qua||fy for Med|ca|d part way through the year |f your out-of-
pocket spend|ng on med|c|nes or other hea|th care s|gn|f|cant|y reduces the |ncome you have
|eft for ||v|ng expenses.}
º You have coverage from a state program |n add|t|on to Med|care.
º You have an 'enhanced" Med|care prescr|pt|on drug p|an or a Med|care Advantage P|an that
prov|des extra coverage dur|ng the gap, poss|b|y even e||m|nat|ng |t. You may sw|tch to one of
these p|ans dur|ng the next enro||ment per|od (genera||y November 15 through December 31,
Some drug compan|es offer f|nanc|a| ass|stance for the|r med|c|nes. To app|y for these programs, v|s|t
www.he|p|ngpat|ents.org or ca|| the Partnersh|p for Prescr|pt|on Ass|stance at 1-888-477-2669.
lf you th|nk you may be affected by the coverage gap, read on to f|nd out more about how |t works.
each year}.
the major|ty of Med|care benef|c|ar|es and on|y app||es to those who have Med|care
does not
affect
8/2010
PTC-008R10
Monthly Expenses for Covered Drugs
Mary Paid: Plan Paid: Total Drug Cost:
January $360.00 $360.00 $720.00
February $180.00 $540.00 $720.00
March $180.00 $540.00 $720.00
April $230.00 $490.00 $720.00
Total expenses from
January to April
$950.00 $1,930.00 $2,880.00
May $720.00 $0 $720.00
June $720.00 $0 $720.00
July $720.00 $0 $720.00
August $720.00 $0 $720.00
September $720.00 $0 $720.00
Total expenses from
January to September
$4,550.00 $1,930.00 $6,480.00
October $36.00 $684.00 $720.00
November $36.00 $684.00 $720.00
December $36.00 $684.00 $720.00
You can find out how much your plan paid by looking at your pharmacy receipt.
• The amount you paid plus the amount your plan paid is your total drug cost. Add your total drug costs
each month to see how close you are to entering the coverage gap. Remember, in 2010 you enter the
coverage gap when your total drug costs reach $2,830.
• Add the total amounts you paid each month to find out how close you are to exiting the coverage
gap. In 2010, the out-of-pocket limit for most plans that have a coverage gap is $4,550.
Mary paid more in
January because she
had to meet her $310
deductible before her
plan started to pay
toward the cost of her
medicines.
Mary entered the
coverage gap in April
because her total drug
costs (what she paid
plus what her plan
paid) reached $2,830.
Mary exited the
coverage gap at the
end of September
because the total
amount that she
paid herself for her
medicines reached
$4,550.
In October, Mary
entered “catastrophic
coverage.” She paid
5% of the cost for her
medicines and her
plan paid the rest.
Sample Expense Log
It’s important to track your spending to see when you will enter and exit the coverage gap. The
sample Expense Log below shows you how.
Mary has Medicare prescription drug coverage for the seven medicines she takes every month. Her
plan has a $310 deductible at the beginning of the year and Mary pays a copay for each of her
prescriptions. Your plan may be different than Mary’s.
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Resources for Medicare Beneficiaries:
Navigating the Coverage Gap
YourPharmacyBenef|t.org
1894 Preston Wh|te Dr|ve
Reston, vA 20191
How the Gap May Affect You
www.Yvu·1¡u·mu.,BeneJ.:.v·g
Resources for Medicare Beneficiaries:
Navigating the Coverage Gap
How the Gap May Affect You
What is the Coverage Gap?
The coverage gap (somet|mes ca||ed the 'donut ho|e"} |s when Med|care temporar||y stops pay|ng
for your prescr|pt|ons and you have to pay the ent|re cost yourse|f. The coverage gap
prescr|pt|on drug coverage. You may see ||tt|e or no |mpact from the coverage gap |f:
º You have very |ow drug costs each year.
º You have 'extra he|p" (||m|ted |ncome subs|dy} from Med|care or the Soc|a| Secur|ty
Adm|n|strat|on.
º You have Med|ca|d. (You may qua||fy for Med|ca|d part way through the year |f your out-of-
pocket spend|ng on med|c|nes or other hea|th care s|gn|f|cant|y reduces the |ncome you have
|eft for ||v|ng expenses.}
º You have coverage from a state program |n add|t|on to Med|care.
º You have an 'enhanced" Med|care prescr|pt|on drug p|an or a Med|care Advantage P|an that
prov|des extra coverage dur|ng the gap, poss|b|y even e||m|nat|ng |t. You may sw|tch to one of
these p|ans dur|ng the next enro||ment per|od (genera||y November 15 through December 31,
Some drug compan|es offer f|nanc|a| ass|stance for the|r med|c|nes. To app|y for these programs, v|s|t
www.he|p|ngpat|ents.org or ca|| the Partnersh|p for Prescr|pt|on Ass|stance at 1-888-477-2669.
lf you th|nk you may be affected by the coverage gap, read on to f|nd out more about how |t works.
each year}.
the major|ty of Med|care benef|c|ar|es and on|y app||es to those who have Med|care
does not
affect
8/2010