Coverage Limits and Extra Help 2023
Coverage Limits
You've probably heard about the "coverage gap" (sometimes called the "donut hole") in prescription drug coverage. What exactly is this?
Our Part D Prescription Drug benefit has three or four different phases that a member might go through depending on their plan. Each year, Medicare announces what the various limits are for each of these phases.
Phase 1 is called the Deductible Phase.
For 2023, all Value Plus plan members and Select plan members in Aroostook, Hancock, Kennebec, Penobscot, Piscataquis, Somerset and Washington Counties in Maine; and Belknap, Carrol, Coos, and Grafton Counties in New Hampshire have deductible phases. For Tier 3, 4, and 5 drugs, you must first meet your $275 deductible. There is no deductible for Tier 1 and 2 medications; you only pay a small copayment or coinsurance. The copayment/coinsurance is determined by what type of drug you are receiving as well as which pharmacy you use. For Tiers 3, 4, and 5, you pay the full cost of the drug until you reach your deductible.
Phase 2 is called the Initial Coverage Phase.
For 2023, you will be in the Initial Coverage Phase until the amount you pay plus the amount the plan has paid reaches $4,660 for covered prescription drugs. At that point, your coverage enters Phase 3 the Coverage Gap Phase.
Phase 3 is called the Coverage Gap Phase.
In this phase you will receive a discount on brand-name drugs and you pay only 25% of the costs of generic drugs. You stay in this phase until your "out-of-pocket costs" reach a total of $7,400. This amount and the rules for counting costs toward this amount have been set by Medicare.
Phase 4 is called the Catastrophic Coverage Phase.
In this phase, your cost sharing will be the greater of 5% coinsurance or $4.15 for generics and $10.35 for all other drugs.
You can also find more details about Coverage Limits in the Summary of Benefits.
If You Qualify for Assistance
If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. The amount of Extra Help you get will determine your total monthly plan premium as a member of our plan.
The tables below show you what your monthly plan premium will be if you get Extra Help.This does not include any Medicare Part B premium you may have to pay.
*Please note Extra Help amounts are determined by each individual state.
2023 Prime Plan: Premium $89.00
Maine Counties: Lincoln, Oxford, Piscataquis, Somerset, and Waldo;
New Hampshire Counties: Belknap, Carroll, Coos, and Grafton
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $31.10 | $57.90 |
| 75% | $23.30 | $65.70 |
| 50% | $15.60 | $73.40 |
| 25% | $7.80 | $81.20 |
2023 Prime Plan: Premium $29.00
Maine Counties: Aroostook, Franklin, Hancock, Knox, Penobscot, and Washington
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $29.00 | $0 |
| 75% | $21.80 | $7.20 |
| 50% | $14.50 | $14.50 |
| 25% | $7.30 | $21.70 |
2023 Prime Plan: Premium $0
New Hampshire Counties: Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, and Sullivan
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
2023 Prime Plan: Premium $0
Maine Counties: Cumberland
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
2023 Prime Plan: Premium $29.00
Maine Counties: Kennebec and Sagadahoc
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $29.00 | $0 |
| 75% | $21.80 | $7.20 |
| 50% | $14.50 | $14.50 |
| 25% | $7.30 | $21.70 |
2023 Prime Plan: Premium $0
Maine Counties: York
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
2023 Prime Plan: Premium $0
Maine Counties: Androscoggin
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
2023 Value Plus Plan: Premium $0
Maine Counties: Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, and Washington
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
2023 Value Plus Plan: Premium $0
Maine Counties: Kennebec, Sagadahoc
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
2023 Select Plan: Premium $99.00
Maine Counties: Androscoggin, Cumberland, Franklin, Knox, Lincoln, Oxford, Sagadahoc, Waldo, and York; New Hampshire Counties: Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, and Sullivan
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $31.10 | $67.90 |
| 75% | $23.30 | $75.70 |
| 50% | $15.60 | $83.40 |
| 25% | $7.80 | $91.20 |
2023 Select Plan: Premium $99.00
Maine Counties: Aroostook, Hancock, Kennebec, Piscataquis, Somerset, and Washington; New Hampshire Counties: Coos
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $31.10 | $67.90 |
| 75% | $23.20 | $76.70 |
| 50% | $15.60 | $83.40 |
| 25% | $7.80 | $91.20 |
2023 Select Plan: Premium $0
New Hampshire Counties: Belknap, Carroll, and Grafton
| Your level of extra help | Medicare pays |
Your new adjusted Premium |
|---|---|---|
| 100% | $0 | $0 |
| 75% | $0 | $0 |
| 50% | $0 | $0 |
| 25% | $0 | $0 |
Part D Prescription Drug Coverage
Martin's Point Generations Advantage Prime, Select, Value Plus, and Focus DC plan premiums include coverage for both medical services and Part D Prescription Drug coverage.
Please see the Evidence Of Coverage for Prime, Select, Value Plus, and Focus DC Ch. 6, Section 6.1 for more details.
The State will notify you what your Extra Help Level of coverage will be. The table below lists what your prescription cost share will be if you get Extra Help.
| Prescription cost share |
Generic |
Brand |
|---|---|---|
| Level 1 | $4.15 | $10.35 |
| Level 2 | $1.45 |
$4.30 |
| Level 3 | $0 | $0 |
| Level 4 | 15% of drug cost |
15% of drug cost |
If you aren't getting Extra Help, you can see if you qualify by calling:
- 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day, 7 days a week)
- Office of MaineCare Services (Medicaid) at 1-800-321-5557. TTY/TDD users should call 1-800-423-4331
- New Hampshire Department of Health and Human Services (Medicaid) Strafford County at 1-800-862-5300, Hillsborough County Manchester Office at 1-800-852-7493, Hillsborough County Southern District Office at 1-800-852-0632, TTY/TDD users should call 1-800-735-2964 (access relay for all NH counties)
- The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 7 am-7 pm, Monday through Friday
- Your local Area Agency on Aging
- Viewing the Best Available Evidence (BAE) Policy online
For More Information
If you're a current member, call Member Services at 1-866-544-7504, (TTY: 711), 8 am-8 pm, seven days a week from October 1 - March 31, and Monday through Friday the rest of the year.
If you're not a member, our representatives will be glad to answer your questions. We can be reached toll-free, 1-800-603-0652 (TTY:711), 8 am-8 pm, seven days a week from October 1 to March 31, and Monday through Friday the rest of the year.