Initial Stage: You pay the plans applicable cost share of first $4460 in Rx purchased, your share would be a maximum of $1544 of $4660. (Usually much lower)
Coverage Gap/Donut Hole: You pay 25% of the cost of brand & generic drugs.
Catastrophic Stage: This stage starts when the amount YOU paid in the “Initial Stage”, plus the amount YOU paid in the “gap”, plus the 70% discount YOU received on brand name Rx during the “gap”, totals $7400. For the remainder of the year you pay 5% of the cost of your Rx, if greater than $10.35 for brands and $4.15 for generics. If you reach this stage, you’ll have paid about $2863. (If you purchased brand name only in the gap. The amount you spent will be higher if you purchased more generics in the gap)
Cost management restrictions for some prescriptions:
Quantity Limits:
For safety and cost reasons, plans may set quantity limits on the amount of drugs they cover over a certain period of time. For example, a person may be prescribed a medication to take two tablets per day, or 60 tablets per month. If the plan has a quantity limit of 30 tablets per month for that medication, your doctor or prescriber will need to work with the Medicare Prescription Drug Plan to get authorization for a higher quantity.
Prior Authorization:
Prior authorization means that you and/or your prescriber must contact the drug plan to determine if specific criteria is met before you can fill certain prescriptions. Call your plan or visit their Web site to learn more about specific prior authorization requirements. Many prior authorization requirements can be resolved at the point of sale and don’t require any additional information from your doctor. Knowing what the prior authorizations are before going to your doctor’s office may save you time at the pharmacy counter.
Step Therapy:
Step therapy is a type of prior authorization. In most cases, you must first try a less expensive drug on the Medicare Prescription Drug Plan’s formulary (also called a drug list) that has been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. This might mean trying a similar, more affordable generic drug instead of a more expensive, brand-name medication. The more affordable drugs in the first phase are known as “Step 1” prescription drugs. Please note that the formulary may change at any time. You will receive notice when necessary.
However, if you have already tried the more affordable drug and it didn’t work or if your prescriber believes that it is medically necessary for you to be on a more expensive drug, he or she can contact the plan to request an exception. If your prescriber’s request is approved, the plan will cover the more expensive drug. The more expensive drugs are known as “Step 2” prescription drugs, and Medicare will not cover them until Step 1 drugs are first tried unless an exception is obtained.