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Understanding drug payment phases

Amount varies per plan

Deductible phase

 

In this phase, if your plan has a deductible, you usually pay the full, negotiated price of your drugs, up to the deductible amount. To count toward the deductible, drugs must be in your plan’s formulary. Once you reach the deductible amount, the deductible phase ends. The initial coverage phase then begins.

 

Plan deductibles for 2022 plans apply to:

 

SilverScript® Choice (PDP)
Tiers 3–5

 

SilverScript SmartRx (PDP)
Tiers 2–5

 

SilverScript Plus (PDP)
No deductible

Up to $4,430

Initial coverage phase

 

During this 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 pay $4,430 for your medicines. Once you reach $4,430 for your drugs, you enter the coverage gap or “donut hole.”

Up to $7,050

Coverage gap phase

 

During this phase, you’ll receive limited coverage on certain drugs. For generic and brand-name drugs, you’ll pay 25 percent of the cost. This phase continues until your yearly out-of-pocket drug costs reach $7,050. Once your yearly out-of-pocket costs reach $7,050, you move to the catastrophic coverage phase.

Catastrophic starts at $7,050 in 2022

Catastrophic coverage phase

 

In this phase, you’ll pay only a small copay or coinsurance for each prescription you fill.                                                                                                                                                                            

Have questions about drug payment phases?
Just call the number on your member ID card. We’re here to help.

 

We help you track your progress toward the coverage gap

 

For each month that you use your coverage, your plan provides an Explanation of Benefits (EOB) statement. You may receive these by mail. Or you can find up to 36 months of online statements on your secure Caremark.com account. Refer to your most recent EOB to confirm which coverage phase you’re in. It can help you to keep track of your progress toward the gap.

 

Looking for ways to reduce paper clutter and stay organized? Go paperless by opting in to view your EOB statements online. Log in to your Caremark.com account to opt in. We’ll then send you an email to let you know when a new EOB statement is available to view online. Click the link in your email to access, view and print your EOBs. You’ll be able to see your current EOB statement, plus up to three years of your EOB history. (You can opt out and return to paper statements at any time.)

Coverage Gap FAQs

 

Medicare created the four coverage phases — including the coverage gap — as part of all Part D plans, not just this one. Some plans offer additional coverage in the gap, such as SilverScript® Plus.

This amount is sometimes referred to as “Total Drug Costs.” It includes:

 

  • All deductibles, copays and coinsurance you have paid in the current plan year.
  • The amount your Part D plan has spent toward the cost of your covered drugs in the current plan year.

It does not include your monthly plan premium.

This amount is sometimes called “True Out-of-Pocket” or “TrOOP.” It includes:

 

  • The deductibles, copays and coinsurance you have paid in the current plan year.
  • The discount on brand drugs you receive while in the coverage gap.
  • Any amount paid on your behalf by other organizations, like the Extra Help program. 

It does not include your monthly plan premium.

Your monthly plan premium payments are not included in your Total Drug Costs, or TrOOP.

You may be able to delay your entry into the gap, or avoid it completely, by choosing less expensive drugs when possible. Check with your doctor to find out whether a different covered drug will cost you less and be appropriate for your treatment.

Disclaimer

Aetna and CVS Caremark® are part of the CVS Health® family of companies.

The formulary and pharmacy network may change at any time. You will receive notice when necessary.