Aetna Insurance: Understanding The Gap Phase

The gap phase in Aetna insurance refers to the coverage gap or donut hole phase in Medicare prescription drug plans. This phase occurs when an individual and their drug plan have spent a certain amount on prescription drugs, after which their discount is reduced. During this phase, individuals pay a higher percentage of the cost of their prescription drugs until their yearly out-of-pocket costs reach a certain amount, at which point they move to the catastrophic coverage phase.

The deductible phase

• SilverScript® Plus (PDP) Tiers 3–5
• SilverScript® Choice (PDP) All Tiers
• SilverScript® SmartRx (PDP) Tiers 2-5

During the initial coverage phase, you'll pay a copay or coinsurance (your share of the cost) for each prescription you fill. This continues until you and your plan have paid $5,030 for your medicines. Once you reach $5,030 for your drugs, you enter the coverage gap or "donut hole".

During the coverage gap phase, you will receive limited coverage on certain drugs. For generic and brand-name drugs, you will pay 25% of the cost. This phase continues until your yearly out-of-pocket drug costs reach $8,000. Once your yearly out-of-pocket costs reach $8,000, you move to the catastrophic coverage phase.

In the catastrophic coverage phase, you will have 0 copays for all covered Part D Drugs. If your plan covers excluded drugs, initial coverage cost-shares will apply. You will stay in this phase through the end of the plan year.

The initial coverage phase

During the initial coverage phase, you will pay a copayment or coinsurance for the discounted price of each prescription you fill. This is your share of the cost, and it continues until your total drug costs (what you and your plan pay) reach $5,030. Most people will remain in this phase. Once the initial coverage limit of $5,030 is reached, you enter the coverage gap or "donut hole".

The amount you pay during the initial coverage phase is sometimes referred to as "Total Drug Costs". It includes all deductibles, copays and coinsurance you have paid in the current plan year, as well as the amount your Part D plan has spent towards the cost of your covered drugs in the current plan year. It does not include your monthly plan premium.

During the initial coverage phase, you can get the most out of your plan by checking different ways to save money, such as reduced pricing at preferred pharmacies, extra benefits, or 90-day drug prescriptions.

The coverage gap or donut hole phase

The coverage gap or "donut hole" phase is the second of the four drug payment phases in Medicare. This phase begins when you and your plan have paid a combined total of $5,030 for your medicines. During this phase, you will receive limited coverage on certain drugs. You will pay 25% of the cost of generic and brand-name drugs. This phase continues until your yearly out-of-pocket drug costs reach $8,000, at which point you will move to the catastrophic coverage phase.

The catastrophic coverage phase

In the catastrophic coverage phase, you will pay nothing for your covered Part D drugs for the rest of the calendar year. You will remain in this phase through the end of the plan year.

The donut hole

The "donut hole" is a metaphoric term for the coverage gap in drug costs for Medicare recipients. In other words, it is a temporary limit on what a Medicare Part D plan will pay for drugs for a specified period. This coverage gap is one of the four stages of the yearly Medicare cycle of drug coverage.

There are several strategies to avoid the donut hole, such as switching to lower-cost generic drugs, using prescription assistance programs, and using your Part D plan's preferred pharmacy. Additionally, people enrolled in Extra Help, a Medicare program for people with limited resources, will not enter the donut hole.

Frequently asked questions