Although the Medicare Part D policy helps reduce the burden of drug costs, policy holders still have to bear significant out of pocket expenses. These include deductibles and the expenses incurred in the coverage gap period. As of 2013, out of pocket expenses incurred by policy holders have come down to 47.5 percent on branded drugs and 79 percent on generic drugs. In order to reduce the burden of the Medicare Part D coverage gap, a discount program has been formulated by the Centre for Medicare and Medicaid Services (CMS). Here is an overview of this program.
To understand the discount program, it is important to understand the concept of applicable drugs. These are drugs that are covered by Part D plans and approved under NDAs or New Drug Applications. The drugs could also be licensed under BLAs or Biologics License Applications. All these drugs, branded or generic, are approved by the FDA. Applicable drugs can be included under Part D only if the manufacturer signs a specially formulated discount agreement with CMS.
How does the discount program work?
Discounts for applicable drugs are issued at the point of sale location, which in most cases are the pharmacy stores. You pay the remaining cost of the drug. From 2013 onwards, the government has started giving a 2.5 percent subsidy on branded drugs. So the total cost that goes out of your pocket reduces by a large margin.
The full cost of the drug is calculated as your out-of-pocket expense although you don’t pay the full cost. This is done in order to speed up the process of reaching the upper limit of the Medicare part D coverage gap. You reach catastrophic coverage limit sooner and can leave the donut hole.
Some manufacturers might refuse to sign a discount agreement. In such cases, the applicable drug manufactured by that company is not included in Part D Medicare. The law does not prevent a Part D beneficiary from buying those drugs. However, the beneficiary has to bear full price and is not eligible for the 52.5 percent discount. Additionally, The cost of the drug will not be counted when cumulating your out of pocket expenses. Despite spending more, you do not reach the catastrophic coverage limit soon.
How do you know which manufacturers have signed the discount agreement with CMS?
You can obtain full benefits of the discount program only if you buy drugs from brands that have signed an agreement with CMS. In order to help people obtain this benefit, CMS publishes a list of companies who have entered the agreement. Along with the names, a five digit code that is associated with each company is also provided. You can access the list at the official website of CMS.
What are the eligibility criteria for Medicare Part D coverage gap discount program?
According to CMS, beneficiaries are eligible for the Medicare part D coverage gap discount program under three circumstances:
- Everybody enrolled in Part D, Advantage Plan, Employer Group Health Plan or Waiver plan for drug coverage
- Anybody who does not receive Extra Help. This is a program sponsored by Medicare for the benefit of people who live on limited resources and pay the costs of Part D covered drugs
- Everybody who is enrolled in Part D Medicare and has entered the Medicare part D coverage gap
If you are eligible for the discount program but do not receive benefits, you can file complaints with the Plan D regulation body. The contact number of the concerned office is provided on your membership card. For complaints related to this program, you can also call Medicare helpline at 1-800-633-4227 or 1-877-486-2048.