Medicare Catastrophic Drug Coverage
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Medicare has catastrophic drug coverage that goes into effect after you have gone through the gap. All plans are required to start catastrophic coverage once your total out of pocket expenses minus premiums has reached $4050 for 2008. Out-of-pocket expenses count only for drugs covered under your plans formulary or exception. This catastrophic coverage will remain in effect for the rest of the year.
Non formulary
If your doctor has ordered a medication that is not on your plans formulary you will pay the full cost for that medication and this cost will not count toward your total out of pocket expenses in regards to the gap and catastrophic coverage. If the medication that your doctor has ordered is the only one that will work for you than you can present the proof of what other meds were tried and their results to your plan. They will then review this information to determine if they need to make an exemption for that particular medication for you. This becomes a very large factor, if say you have a heart or seizure medication that is not on the formulary and all the others you tried don’t work but that medication costs $300-$500 or more a month. You will be paying this total cost without the plans discount and that amount of $3600-$6000 per year is not counted toward your catastrophic benefits. One non formulary medications costs could put you into catastrophic coverage thereby lowering your total drug outlay by thousands. Making sure your plan’s formulary includes all your medications or will make exemption for them is really important to your financial health
EOB
Each month you will receive an “Explanation of Benefits” from your plan. This document will show you how much you have spent and where you are in regards to the coverage gap. You will need to evaluate this information each month and verify its accuracy.
Catastrophic drug costs
Once you have reached the catastrophic amount for your prescription medications you’re out-of-pocket drug expenses will change again. This time they will go down significantly. You will now have a small co-payment of 5% or you will pay $2.25 for generics and $5.60 for brand names, whichever is greater. Unlike the coverage before the gap, there is no coverage limit once this level has been reached.
Tracking expenses
It is your drug plans responsibility to keep track of how much out-of-pocket money you have spent. It is wise to keep your pharmacy receipts to verify you’re your plans information is accurate. If you have been in the gap and medications were paid by different sources some of that money spent may be applied to your overall- out-of pocket expense. If you paid for medications using a pharmacy card during the gap you will need to send in your receipts to your plan so that these expenditures can be counted toward your catastrophic coverage.
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