- Plan Name: This is the official Medicare Part D prescription drug plan or Medicare Advantage name from the
Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different
Plan ID in each state (or CMS Region). The plan name is followed by the plan type
- Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
- Deductible: If your Part D plan has an initial deductible,
you are 100% responsible for your drug costs until your expenses exceed this value
and you begin your Initial Coverage Phase.
- Some Part D plan providers offer an initial deductible lower than the Standard deductible.
- Gap Coverage (the Donut Hole): In the CMS Standard Plan,
the beneficiary, or others on their behalf (e.g. the brand-name drug manufacturer discount), pay(s)
up to $5,019 in drug costs, depending on your mix of generics and brand-name drugs.
The Healthcare Reform provides that for plan year 2020,
ALL formulary generics will have at least a 75% discount and
ALL brand-name drugs will have at least a 75% discount in the coverage gap. The Gap Coverage Types discussed in this section are in addition to the Healthcare Reform mandated discounts. In our chart, you will see one of the following:
- Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
- Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
(Chart Source: Centers for Medicare and Medicaid files: CMS Data June 2020 )