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Gap Assistance Pharmacy Program for Seniors (GAPS)

South Carolina Department of Health and Human Services

Medicare began providing prescription drug coverage for people eligible for Medicare on January 1, 2006. The South Carolina prescription drug coverage program for seniors eligible for Medicare is called the Gap Assistance Pharmacy Program for Seniors or GAPS.

GAPS (Gap Assistance Pharmacy Program for Seniors) works with Medicare's prescription drug (Part D) coverage this way:

Most people who join a Medicare Prescription Drug Plan, after paying a monthly premium, will be responsible for 100% of their drug costs between $2,830 to $6,440. This gap in Medicare drug coverage that many people will face is referred to as the "doughnut hole." GAPS will provide state pharmacy assistance to "fill the gap" for qualifying seniors' Medicare prescription drug coverage when their drug costs reach the "doughnut hole". With GAPs, seniors will have to pay 60% of their prescription costs between $2,830 to $6,440, rather than having to pay for their drugs without this state assistance. Coverage under the GAP program begins the first day of the month following the month in which SCDHHS determines GAP eligibility.

Qualifying: To be eligible for prescription coverage through GAPS, you must be a SC resident, meet citizenship and alien requirements, be age 65 or older, and have gross household income below 200% of the Federal Poverty Level.

200% of Poverty Level as of March 1, 2009

Family Size Monthly Income Annual Income
1 $1,805 $21,660
2 $2,428 $29,140
3 $3,052 $36,620
4 $3,675 $44,100
5 $4,298 $51,580
6 $4,922 $59,060
7 $5,545 $66,540
8 $6,168 $69,223

For each additional family member, add $7,200 to the annual income. For the monthly, divide by 12 then round up to the next whole dollar for the monthly income.


Before you apply for GAPS, you will need to:
Check to see if you qualify for Extra Help through the Federal government with your prescription drug costs. The Extra Help program is for those with limited income and resources. Monthly income must be below 150% of the Federal Poverty Level (FPL), $1,354 ($1,822 for a couple) and countable resources must be below $12,510 ($25,010 for a couple). Individuals eligible for Extra Help will not experience the doughnut hole and will not need GAPS. If you have not already checked to see if you qualify for Extra Help, please do so. Online applications are available at www.socialsecurity.gov or call (toll-free) 1-800-772-1213. (Note: You do not need GAPS if you qualify for Extra Help.)

If you qualify for GAPS, you will need to join a Medicare Prescription Drug Plan (PDP). Medicare prescription drug coverage does not begin until you have joined a drug plan. To benefit from GAPS, you must select a PDP that is participating in GAPS. Not all PDPs participate in GAPS. Listed below are the participating providers and the Prescription Drug Plans that are participating in GAPS along with their toll-free telephone numbers.

People with Medicare can choose to sign up for prescription drug coverage through Medicare Part D. Medicare-eligible individuals may voluntarily enroll in a Part D Prescription Drug Plan (PDP), regardless of income, health, or the manner in which they are now paying for their prescriptions.

Steps to Take:

  1. Contact the Social Security Administration to see if you qualify for the Extra Help program. If so, you can sign up with a Medicare Part D Prescription Drug Plan (PDP) with little or no monthly fees and only a small payment (co-pay) for each prescription. People in the Extra Help program will have no gap or "doughnut hole" in their Medicare prescription drug coverage. Call 1-800-772-1213 or visit Social Security online at: www.socialsecurity.gov.


  2. Enroll in the South Carolina Gap Assistance Pharmacy Program for Seniors (GAPS) if you do not qualify for Medicare's Extra Help and if you are GAPS-eligible. This is a state-funded program administered by the South Carolina Department of Health and Human Services (DHHS). If your prescription costs make you reach the Medicare Part D "gap or doughnut hole" then the GAPS program will cover 60% of your prescription costs while you are experiencing the prescription coverage gap. If you do not expect your prescription expenses in 2010 to be $2,830, then you would not likely benefit from the coverage available through the GAPS program. It is important that you select a PDP that coordinates with GAPS if you qualify for and enroll in GAPS. To learn more, call 1-888-549-0820 or visit DHHS online: www.dhhs.state.sc.us.


  3. Make a list of your prescription drugs, the drug strengths, and the dosages. Contact your local Senior Center OR the Lt. Governor's Office on Aging OR Medicare (1-800-633-4227) to get help finding the right prescription drug plan for you. Let them know if you qualify for Medicare's Extra Help program (see number 1 above) or if you are receiving Medicaid benefits. You can also use the Internet to find the PDP that is right for you! Just go to www.medicare.gov. On the right side of the Medicare Website, choose "Compare Prescription Drug Plan" and follow the instructions given.


  4. Choose one of the prescription drug plans identified for you. If the plan costs too much for you, then find out if there is a less expensive plan that covers most of the drugs prescribed for you or the most expensive drugs that you need.

Things to Remember:

  • Annual open enrollment for Medicare Part D occurs annually November 15th through December 31st. After open enrollment ends, S. C. GAPS-eligible individuals have a one-time only opportunity, during the calendar year, to change from their current Prescription Drug Plan to another PDP.


  • If you are new to Medicare, then you can enroll in a Medicare Part D plan from three months before you turn 65 to three months after you turn 65.


  • If you already have prescription drug insurance, make sure you have a letter from your insurance company that states your drug coverage is as good as the Medicare Part D Prescription Drug Program.


  • Choosing the right Part D plan helps with paying for prescriptions that you take now. Also, you may need additional and more expensive prescriptions later. If that occurs, then it will be important to have Medicare Part D coverage.

If Medicaid and Medicare-Eligible:

If you are eligible for both Medicaid and Medicare and are having problems getting your medications, call the SC Department of Health and Human Services at 1-888-549-0820.

Medicare Prescription Drug Coverage does not begin until an individual joins a drug plan. To benefit from GAPS, an individual must select a PDP that is participating in GAPS. Not all PDP's will be participating in GAPS. The following plans will participate with GAPS. GAPS beneficiaries must join one of these plans to get drug cost savings.

The following Medicare Plans are participating with GAPS in 2010

Medicare Part D Drug Plans Plan Phone Number
United Healthcare (S5820) AARP MedicareRx Preferred (008) 888-867-5564
EnvisionRx Plus (S7694) Silver Plan (009) 866-250-2005
Fox Insurance Company (S5557) Value Plan (038) 888-369-7979


Medicare Part C Health Plans Plan Phone Number
Care Improvement Plus (R9896) Gold Rx (002) 866-766-8698
Care Improvement Plus (R9896) Platinum Rx (003) 866-766-8698
Care Improvement Plus (R9896) Silver Rx (001) 866-766-8698
Care Improvement Plus (R9896) Gold Rx Advantage (004)
866-766-8698
Care Improvement Plus (R9896) Platinum Rx Advantage (007) 866-766-8698

Note: GAPS is not a Medicaid program; however, it is administered by the South Carolina Department of Health and Human Services. Please contact your local Medicaid office if you have never applied for Medicaid benefits and think you may qualify. If you do not know where to go, visit the agency's web site at www.scdhhs.gov or call (toll-free) 1-888-549-0820. Medicaid coverage will benefit you more than GAPS.

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Friday, October 31, 2014