Coverage Limits and Extra Help 2021

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 2021, the Value Plus and Flex plans both 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 2021, you will be in the Initial Coverage Phase until the amount you pay plus the amount the plan has paid reaches $4,130 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 $6,550. 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 $3.70 for generics and $9.20 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.

2021 Prime Plan: Premium $89.00

Maine Counties: Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, and Washington; New Hampshire Counties: Belknap, Carroll, Coos, and Grafton

2021 Prime Plan: Premium $29.00

Maine Counties: Androscoggin, Kennebec, and Sagadahoc

2021 Prime Plan: Premium $0

New Hampshire Counties: Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, and Sullivan

2021 Value Plus Plan: Premium $29.00

Maine Counties: Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, and Washington

2021 Select Plan: Premium $99.00

All Maine Counties

All New Hampshire Counties

2021 Flex Plan: Premium $53.00

All Maine and New Hampshire Counties

Martin's Point Generations Advantage Prime, Select, Value Plus, Focus DC, and Flex 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, Focus DC, and Flex 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.