However, calculating the discount will consider:
- Is the drug eligible for the Donut Hole discount? (Is the medication included on your Medicare Part D formulary - or has this non-formulary drug been added to your Part D plan coverage because you have been granted a formulary exception whereby your non-formulary drug is being covered by your plan? (Non-formulary drugs will not receive a Donut Hole discount.)
- Is the drug excluded from the Medicare Part D program and therefore not eligible for a discount?);
- Is the Medicare beneficiary eligible for the Donut Hole discount? (For example, is the beneficiary eligible for the Medicare Part D low-income subsidy (LIS) and therefore does not have a Donut Hole in Part D coverage?);
- Is the purchase wholly or partially in the Coverage Gap or still in the Initial Coverage Phase? (If partially in the Donut Hole, the purchase will be calculated as a Straddle Claim with only the portion* of the purchase in the Coverage Gap receiving the Donut Hole discount.) and;
- The amount of the discount, taking into consideration the plan’s supplemental benefits that pay first (for instance, does your Medicare plan have coverage in the Donut Hole?).
The Medicare Part D plan will be the organization responsible for calculating and communicating the discount to the pharmacy because they are the only entity with all necessary pieces of your Medicare Part D plan information.
*For example, if a non-LIS beneficiary fills a prescription for a formulary drug with a $100 retail price when he/she is $40 below the plan's initial coverage limit, only $60 of the drug's retail price would fall into the Coverage Gap and therefore, only the $60 would be be subject to the annual 75% Donut Hole discount