Coverage Gap Details
How does the Coverage Gap or “Doughnut Hole” Subsidy Work?
Once you reach $2,850 in yearly drug costs, you will enter the coverage gap or “doughnut hole.” For Maryland SPDAP members, who are enrolled in one of the 12 Medicare Part D subsidy plan options that have agreed to offer the coverage gap subsidy on behalf of the SPDAP (click here for participating plans), the Senior Prescription Drug Assistance Program will pay 95% of the entire drug costs for members while in the Coverage Gap (Doughnut Hole), and the member is only responsible for a 5% coinsurance plus the non-formulary drug cost.
The subsidy will be provided by using your existing Medicare plan ID card and identification number. You will not need an additional membership card from the SPDAP. If you are taking a brand name drug for which there is a 52.5% discount, your 5% coinsurance will be applied after the discount. If you are taking a generic drug to which your plan has applied a reduction, your 5% coinsurance will be applied after that reduction.
If you are a new member to SPDAP and were already in the “doughnut hole,” when you enrolled, your subsidy will begin on your approval date in SPDAP.
Can I change to a “Doughnut Hole” Plan in Mid-Year, if I’m nearing the Coverage Gap?
As a SPDAP participant, you are permitted to change plans one additional time during the year. If you are concerned that you will have drug expenses exceeding $2,850 and possibly have costs in the coverage gap phase, then you should consider changing your enrollment to one of the Medicare Part D prescription drug plans that have agreed to offer the Maryland coverage gap subsidy (click here for participating plans). To change your current Medicare Part D plan, contact the plan in which you wish to enroll. Once you’ve been accepted in that plan, your information will be given to Medicare, and Medicare will inform SPDAP of your new plan. This will take a few months to finalize.
If you are not enrolled in Maryland SPDAP, you can download an application from the “How to Apply” menu on this website, or contact the SPDAP Call Center toll free at 1-800-551-5995, Monday through Friday, from 8:00 am to 5:00 pm.