Gap Out-of-Network Pharmacy Copay for 1 month supply

SAS Name
GAP_OONP_COPAY_1M

This variable identifies the beneficiary co-payment amount for a 1 month supply of the drugs on this tier, using an out-of-network pharmacy (OONP) during the coverage gap phase of the Part D benefit.

Comments

This variable will only be populated if the plan has an enhanced benefit design with extra coverage in the gap. The coverage gap is technically referred to as the initial coverage limit (ICL) for the Part D benefit. Plans that use a coinsurance percentage rather than a co-payment amount will not have a value in this field; see instead the corresponding co-payment variable called (GAP_OONP_COINS_1M).

The CCW constructs the Plan Characteristics File from information submitted by plan sponsors to CMS’s Health Plan Management System (HPMS). Employer and National Program of All-inclusive Care for the Elderly (PACE) plans are waived from reporting Plan Benefit Package information.

For those plans that did not report, the value of this variable will be blank.

Source: CMS (HPMS Files)