Medicare Part D Coverage Gap
The Medicare Part D prescription drug program consists of four stages: deductible, initial coverage, coverage gap and catastrophic coverage. Your cost for a drug depends on which stage you are in at the time you get your prescription filled or refilled. It is important to understand the coverage gap because you pay for a larger portion of your drug costs during this stage.
Watch this short video or view 2023 Medicare Part D Benefit PhasesOpen a PDF to see how your medication cost may be impacted.
Please note: Some plans may have an annual Part D deductible. If you have a deductible, you will pay the full cost of your Part D medications until your plan deductible is met and you enter the Initial Coverage stage.
These amounts may change on January 1 of each year. This chart reflects dollar amounts for 2023.
You Pay | We Pay | Description | |
---|---|---|---|
Initial Coverage |
Copayment or Coinsurance |
Remaining Cost |
|
Coverage Gap |
25% of the cost for generic and brand name medications |
Partial cost for generic and brand medications |
When you are in the Coverage Gap, you receive limited coverage by Excellus BlueCross BlueShield and a discount on brand name medications.
|
Catastrophic Coverage |
5% coinsurance or $4.15 (generic) or $10.35 (all other medications), whichever is greater |
Remaining cost |
|
How can you avoid reaching the coverage gap?
Using generic medications is the easiest way to avoid reaching the coverage gap. Generics have the lowest copay. Talk to your doctor and/or your pharmacist about using generics.
Want more information?
Refer to your Evidence of Coverage (EOC) for your specific deductible, copayment or coinsurance amounts.
Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_8830_C.
This page last updated 10-01-2022.