The member is responsible for all costs between $2,700 and $6,153 (this gap in coverage is often referred to as the “gap” or “coverage gap”). What is the coverage gap?
• The enrollee pays 5 percent or $2.40 for generics or $6.00 for brand, whichever is greater, for all prescription drug costs greater than $6,153, which equates to $4,350 in the member’s out-of pocket costs. Once the out-of-pocket limit is reached by the member, further drug expenses may be fully covered. The Standard Benefit for those requiring special assistance: People with Medicare who have limited assets, savings and incomes falling below a certain level, may qualify for: • A monthly premium that varies according to income/ asset guidelines. • The government will contribute a percentage of the total premium, reducing or eliminating the amount a person with Medicare must pay. • A $60.00 deductible. • No gap in coverage (between $2,700 and $6,153). • Coinsurance of 15 percent, after $60 deductible, up to the out-of-pocket limit. • Copayments of $2.40 or $6.00 once the out-of-pocket limit is reached. The federal government will provide special assistance to people who are eligible fo
