Coverage Limits and Extra Help - 2019

Coverage Limits

You've probably heard about the "coverage gap" (sometimes called the "donut hole") in prescription drug coverage. What exactly is this?

VALUE PLUS and FLEX MEMBERS ONLY: For Tier 3–5 drugs, you must first meet your $250 deductible (Value Plus) or $295 deductible (Flex) before moving into the Initial Coverage Phase. For any Tier 1 and 2 drugs, you start in the Initial Coverage Phase.

Our Part D prescription drug benefit has three different phases that a member might go through. Each year, Medicare announces what the various limits are for each of these phases.

Phase 1 is called the Initial Coverage Phase. For 2019, you will be in the Initial Coverage Phase until the amount you pay plus the amount the plan has paid reaches $3,820 for covered prescription drugs. At that point, your coverage enters Phase 2 the Coverage Gap Phase.

Phase 2 is called the Coverage Gap Phase.  In this phase you will receive a discount on brand-name drugs and you pay only 37% of the costs of generic drugs. You stay in this phase until your "out-of-pocket costs" reach a total of $5,100. This amount and the rules for counting costs toward this amount have been set by Medicare.

Phase 3 is called the Catastrophic Coverage Phase – In this phase, your cost sharing will be the greater of 5% coinsurance or $3.40 for generics and $8.50 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.

2019 Prime Plan: Premium $89.00
Maine Counties: Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, and Washington; NH Counties: Carroll, Coos, and Grafton

Your level of extra help Medicare pays Your new adjusted Premium
100% $33.20 $55.80
75% $24.90 $64.10
50% $16.60 $72.40
25% $8.30 $80.70

2019 Prime Plan: Premium $19.00
Androscoggin, Kennebec, Sagadahoc, and York Counties

Your level of extra help Medicare pays Your new adjusted Premium
100% $19.00 $0.00
75% $14.30 $4.70
50% $9.50 $9.50
25% $4.80 $14.20


2019 Prime Plan: Premium $29.00
Cheshire, Hillsborough, Rockingham, Strafford, and Sullivan Counties

Your level of extra help Medicare pays Your new adjusted Premium
100% $29.00 $0.00
75% $21.80 $7.20
50% $14.50 $14.50
25% $7.30 $21.70



2019 Value Plus Plan: Premium $29.00
Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, and Washington Counties

Your level of extra help Medicare pays Your new adjusted Premium
100% $29.00 $0.00
75% $21.80 $7.20
50% $14.50 $14.50
25% $7.30 $21.70


2019 Select Plan: Premium $79.00
Maine Counties: Androscoggin, Cumberland, Franklin, Knox, Lincoln, Oxford, Sagadahoc, Waldo, and York; NH Counties: Cheshire, Hillsborough, Rockingham, Strafford, & Sullivan

Your level of extra help Medicare pays Your new adjusted Premium
100% $33.20 $45.80
75% $24.90 $54.10
50% $16.60 $62.40
25% $8.30 $70.70


2019 Select Plan: Premium $99.00
Maine Counties: Aroostook, Hancock, Kennebec, Penobscot, Piscataquis, Somerset, and Washington; NH Counties: Carroll, Coos, and Grafton

Your level of extra help Medicare pays Your new adjusted Premium
100% $33.20 $65.80
75% $24.90 $74.10
50% $16.60 $82.40
25% $8.30 $90.70

2019 Flex Plan: Premium $19.00
All Maine and New Hampshire Counties

Your level of extra help Medicare pays Your new adjusted Premium
100% $19.00 $0.00
75% $14.30 $4.70
50% $9.50 $9.50
25% $4.80 $14.20


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.

Prescription cost share Generic Brand
Level 1 $3.40 $8.50
Level 2 $1.25 $3.80
Level 3 $0 $0
Level 4 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.

Have Questions? Call Us!