© Copyright 2024 – Care N’ Care – All rights reserved. Y0107_24_144_M
Initial Coverage Stage
During this stage, you pay a flat fee (copay) or a percentage of a drug’s total cost (coinsurance) for each prescription you fill.
The plan pays the rest until your total drug costs (paid by you and the plan) reach $4,430.
Coverage Gap Stage
When you are in the Coverage Gap Stage, for most brand name drugs, you pay 25% of the negotiated price and a portion of the dispensing fee. For select Tier 3 brand name drugs, you pay either the Tier 3 copayment or you pay 25% of the negotiated price and a portion of the dispensing fee, whichever is lower. For all other covered brand name, you pay 25% of the negotiated price and a portion of the dispensing fee.
You also receive some coverage for generic drugs. For Tier 1 and select Tier 3 generic drugs, you pay either your Tier 1 or Tier 3 copayment or 25% of the costs, whichever is lower (the plan pays the rest). For all other covered generic drugs, you pay 25% of the costs and the plan pays the rest.
Once your out-of-pocket costs reach $7,050, you move to catastrophic coverage.
Catastrophic Coverage Stage
In this stage, you pay only a small copay or coinsurance amount for each filled prescription.
The plan and Medicare pay the rest until the end of the calendar year.
(also known as the Donut Hole)
