Closing the Coverage Gap in Medicare Part D
Mark Johnson, R.CPhT, Axtell-Rite Pharmacy, Texoma SENIOR MAGAZINE
The Affordable Care Act includes provisions to close the Medicare Part D prescription drug coverage gap (also known as the “donut hole”) to make prescription drugs more affordable for people with Medicare. The first step in closing the coverage gap was the mailing of the one-time $250 rebate check to most people who reached the coverage gap in 2010. The second step to closing the coverage gap starts January 1, 2011.
Starting in January 2011, people with Medicare who have Part D, but don’t get Extra Help (the low-income subsidy), will get a 50% discount under the Medicare Coverage Gap Discount Program on “applicable” drugs at the point-of-sale and a 7% increase in coverage for all other covered Part D drugs (e.g., generic drugs and supplies associated with the delivery of insulin) while they are in the coverage gap. Over the next 10 years, prescription drug coverage will continue to increase for all covered drugs in the coverage gap so what people pay during the gap will continue to decrease until it reaches 25% in 2020.
What are “Applicable” Drugs?
Applicable drugs are Part D prescription drugs approved under new drug applications or licensed under biologics license applications. These are generally covered brand-name Part D drugs including insulin and Part D vaccines. Applicable drugs also include Part D prescription drugs that are commonly considered generic drugs, but actually have been FDA approved. These drugs must be covered by a signed discount agreement to be covered under Part D. Beginning in 2011, only those applicable drugs that are covered under a signed manufacturer discount agreement with the Centers for Medicare & Medicaid Services will be covered under Part D. All other covered Part D drugs and supplies associated with the delivery of insulin) may continue to be covered by Part D plans irrespective of a signed manufacturer agreement. If a drug manufacturer doesn’t sign a discount agreement with CMS, its applicable drugs won’t be covered under Part D, and Part D sponsors won’t be allowed to grant an exception or provide a transition for such drugs. People may still buy the drug at its full price, but the cost won’t count toward getting out of the coverage gap.
If you have any questions, Mark Johnson encourages you to email him at axtellritevaluepharmacy@suddenlink.net, or call him at 903-564-3216.
