Medicare Part D is Medicare Prescription Drug coverage that covers both brand name and generic prescription drugs. GuideStone’s Care Basic and Care Plus plans include Part D prescription drug coverage. This means that for every plan year, participants’ prescription drug coverage has three “zones”:
- Initial coverage zone
- Coverage gap (also known as the “donut hole”)
- Catastrophic coverage zone
Did you know?
Healthcare Reform is phasing out the coverage gap for Medicare Part D drugs. Learn more.
How much the participant and the plan spend on prescription drugs — at times calculated together, at times calculated separately — moves the participants through the "zones." So on both the Care Basic and Care Plus plans, the 2012 prescription drug coverage looks like this:
| Initial Coverage Zone |
Coverage Gap
(aka "donut hole") |
Catastrophic Zone |
- Member pays copays for covered drugs(brand and generic).
- Plan pays balance of drug costs.
- The total of these costs (member copays plus plan payment for drugs) adds up toward the "Coverage Gap."
|
- Member pays lesser of copay or 86% of drug cost for
generic drugs - Member pays 100% of discounted drug cost for preferred and non-preferred drugs (brand-name).
- Member out-of-pocket costs add up toward the "Catastrophic Coverage Zone."*
|
- Member pays the greater of 5% of drug cost or $2.60 generic/$6.50 for brand name.
- Plan pays the balance of plan cost for the duration of plan year.
|
| Zone continues until total drug spend of $2,930 is reached. |
Zone continues until total member out-of-pocket cost reaches $4,700 (annual). |
Zone continues until January 1 when plans resets. |
* Members will actually pay 50% of brand drug cost after a discount from the pharmaceutical manufacturer. The discounted amount will be charged at the pharmacy. The full retail cost of the drugs will still apply to getting out of the donut hole even though 50% was paid for by the pharmaceutical manufacturers.
Moving through the zones:
- Initial coverage zone. Participants stay in this zone until the total drug spend (that is, member copays + plan payment for drugs) reaches $2,930 in 2012.
- Coverage gap. Also known as the “donut hole.” Participants pay the lesser of the copay or 86% of the drug cost for covered generics and 100% of the drug costs for covered preferred and non-preferred (brand name) drugs. Participants stay in this zone until their total out-of-pocket cost (annual) reaches $4,700. *The full retail cost of the drugs will apply to the total member out-of-pocket cost.
- Catastrophic coverage zone. Participants who reach this zone pay the greater of 5% drug cost or $2.60 generic/$6.50 for brand name for the duration of the 2012 plan year.
Frequently asked questions about GuideStone Care Plans.