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Understanding the Medicare Phases
Deductible phase: The annual amount you pay before your plan starts paying. Your deductible is based on the plan type selected.
Initial coverage phase (ICP) This phase starts after you have met your deductible and continues until you and your plan have spent a total of $4660 in 2023. Your co-pay is based on the formulary tier.
Coverage Gap (donut hole) What you pay in the coverage gap for drugs on your plan’s formulary. The most you pay for each prescription while in the coverage gap is 25%.
Items that count towards the coverage gap:
- Your yearly deductible, coinsurance, and copayments
- The discount you get on brand-name drugs in the coverage gap
- What you pay in the coverage gap
Items that don’t count towards the coverage gap
- The drug plan premium
- Pharmacy dispensing fee
- What you pay for drugs that are NOT covered
Catastrophic coverage phase The catastrophic phase starts when you exit the coverage gap and lasts until the end of the calendar year
Medicare Part B Billing
Many of your Henry Ford pharmacies can bill your prescriptions as a medical benefit through Medicare Part B and your qualified supplemental insurance. Eligibility to bill Medicare Part B is dependent on your medical condition and medication.
You must meet the following criteria to qualify and have active coverage through Medicare Part B or Part C Criteria for Transplant Medication:
- You must have had active Medicare Part A or Part C coverage at the time of transplant and Medicare Part A or Part C must have paid toward your transplant.
- You must have a transplant diagnosis
Criteria for Nebulizer Medication:
- Your diagnosis must be approved by Medicare for the prescribed drug
- You must own or rent a nebulizer machine
Criteria for Insulin:
- You must be receiving your insulin through an insulin pump
Criteria Oncology Medication:
- Your diagnosis code must be approved by Medicare for the prescribed drug
Other Important Information:
- The Medicare Part B annual deductible as of 2023 is $226.00
- Medicare Part B will cover 80% of the cost of your medication and leave you with a 20%
coinsurance unless you are insured by a supplement plan.
- Your Part C plan may have a coinsurance or deductible, please refer to your insurance handbook.
- Copays for insulin billed to Medicare Part-B will not exceed $35 for a 30-day supply
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