The Medicare Coverage Gap Discount Program gives your eligible Peoples Health patients discounts on their costs for certain brand drugs during the coverage gap.
Discount Eligibility
To be eligible for the discount, patients must be enrolled in a Medicare plan that provides prescription drug coverage; your Peoples Health patients meet this requirement through their enrollment in a Peoples Health plan. They must also be in the coverage gap for their prescription drug costs and not be receiving extra help from Medicare (also called the low-income subsidy) to pay for prescription drugs. Patients in Peoples Health special needs plans are not eligible for the discount because they receive extra help from Medicare. In addition, patients in Peoples Health group Medicare plans who do not receive extra help from Medicare continue to pay their plan cost-sharing through the coverage gap. This is because their employer or retiree groups provide some drug coverage through this stage.
Eligible Drugs
Drugs eligible for discounts through the program are brand drugs that are:
- Produced by a manufacturer that has signed an agreement with CMS to participate in the program
- Covered by the Peoples Health formulary (including those covered by a formulary exception)
How the Discount Works
Through the program, Medicare works with drug manufacturers to coordinate a discount on the brand drugs the manufacturers make. Peoples Health pays an additional percentage of the cost for eligible brand drugs in the program. Reference a plan’s Evidence of Coverage for the discount amount, which may change each year. The pharmacy that fills the prescription calculates the discount at the point of sale.
Discounted Drugs on the Peoples Health Formulary
Most brand drugs on the Peoples Health formulary are eligible for the program.
The discount is automatically applied to the amount a network pharmacy charges at the point of sale. Your Peoples Health patients’ monthly plan Part D Explanation of Benefits will show any discounts received.
Pharmacies Offering the Discount
Your Peoples Health patients can receive the discount on eligible drugs at any of our network pharmacies. If your Peoples Health patients go to an out-of-network pharmacy and try to use their member ID card to fill a prescription, the pharmacy may not be able to submit the claim directly to Peoples Health. When that happens, patients will have to pay the full cost of their prescription. (Peoples Health covers prescriptions filled at out-of-network pharmacies only in a few special situations.) Patients must save their receipts and send a copy to us when they ask us to pay them back for our share of the cost.
Patient costs may vary slightly due to a small dispensing fee pharmacies typically charge. Dispensing fees generally range from 50 cents to $1.50.
Drug Manufacturer Nonparticipation in the Program
If a drug manufacturer does not agree to participate in the program, Medicare will not cover drugs made by the manufacturer. These would not be considered Part D drugs, and in most cases Peoples Health would not cover them.
Additional Program Information
Patients with questions about the availability of discounts for drugs they take or about the program can visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. Your Peoples Health patients can also call our member services department seven days a week, from 8 a.m. to 8 p.m.