FAQs about Coverage Gap Patient Assistance Programs

Q: What is the Coverage Gap?

There are four “drug payment stages” for your prescription drug coverage:
  1. the Yearly Deductible stage
  2. the Initial Coverage stage
  3. the Coverage Gap stage
  4. the Catastrophic Coverage stage
How much you pay depends on what stage you’re in when you get a prescription filled or refilled. You stay in the Initial Coverage stage until the total amount for the prescription drugs you’ve filled reaches the initial coverage limit for the year set by Medicare ($4,660 for 2023).

Once you go over this amount, you’ll enter the Coverage Gap stage.

Q: How much do I pay for my medications in the Coverage Gap?

During the Coverage Gap stage, you’ll pay 25% of the cost for both generic and brand-name drugs.

You continue paying these costs until your yearly out-of-pocket payments reach the maximum amount Medicare has set. Once you reach this amount ($7,400 for 2023), you leave the Coverage Gap stage and move to the Catastrophic Coverage stage.

The amount you pay in the Coverage Gap may vary depending on whether you have extra help, or your plan offers gap coverage for certain medications. Please refer to your Explanation of Coverage for further details.

Q: What is a Patient Assistance Program (PAP)?

Your drug’s manufacturer may sponsor a patient assistance program (PAP) that offers financial support to low-income individuals. This can help pay for medication costs your health plan does not cover. Each PAP requires an application to verify your income and determine if you meet any remaining requirements.

The help you receive through PAPs does not count towards the true-out-of-pocket (TrOOP) cost that will move you through the different payment stages.

Q: How do I qualify for a PAP?

The requirements for PAPs will vary and depend on your drug’s manufacturer. Requirements are listed in each application. Most PAPs require your doctor to fill out a portion of the application and include their signature.

Q: Where can I find a PAP application for my drug?

Look on the specific drug manufacturer’s website, or use online tools to search for and locate PAPs. One tool we recommend is Needymeds.org:
  • In the drug search bar, type in the name of your medication.
  • Click on the link with your drug’s name.
  • Select the icon for patient assistance programs (image of 2 capsules).
  • Select the program application and form that applies.

Q: Are there other ways to help with my copays during the Coverage Gap?

There may be other organizations or foundations that offer copay assistance based on your condition or treatment. Ask your doctor or pharmacy if they know of any they can connect you with. Some of these programs are listed on Needymeds.org.

Another resource for certain generic medications is Mark Cuban Cost Plus Drug Company, where you can compare costs for your generic medications.

Q: Can I use a manufacturer discount card or program instead?

No. SCAN is a Medicare Advantage plan. And, under federal law, manufacturer discount cards and programs can’t be applied to government-sponsored insurances such as Medicare.
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