2013 Donut Hole Calculation Summary: | |
Summary of the annual retail cost of your drugs:
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Percentage of Generic vs. Brand drug purchases used: | |
0% Generic / 100% Brand (not vaccine adjusted) | |
You will enter the Coverage Gap (Donut Hole): | in April |
You will exit the Coverage Gap (Donut Hole): | in September |
Your total annual Out-of-Pocket Costs without premium: | $2,958.36 |
2013 Donut Hole Calculation Details | |||||||
Month |
Plan Phase |
Who Pays | Total Retail |
||||
You | Plan | Mfgr | Gov | ||||
$$$ | 1: Jan | Deductible | $325.00 | $0.00 | $0.00 | $0.00 | $325.00 |
Your deductible is less than your Rx costs for the month, so here we will use the deductible of $325 and on the next line you will see your initial coverage costs for the remainder of this month. Your costs so far $325. | |||||||
$$ | 1: Jan | Initial Coverage | $118.75 | $356.25 | $0.00 | $0.00 | $800.00 |
You satisfied the remainder of your deductible ($325) earlier this month. Now, in the Initial Coverage phase, you pay 25% of the remaining Rx costs for the month ($475.00) (upto the initial coverage limit--ICL) and your plan pays 75%. Some plan offer copayments instead.* Your costs so far $443.75. | |||||||
$$ | 2: Feb | Initial Coverage | $200.00 | $600.00 | $0.00 | $0.00 | $1,600.00 |
You are in the Initial Coverage Phase. Your costs so far $643.75. | |||||||
$$ | 3: Mar | Initial Coverage | $200.00 | $600.00 | $0.00 | $0.00 | $2,400.00 |
You are in the Initial Coverage Phase. Your costs so far $843.75. | |||||||
$$ | 4: Apr | Initial Coverage | $142.50 | $427.50 | $0.00 | $0.00 | $2,970.00 |
You are in the Initial Coverage Phase. Your costs so far $986.25. | |||||||
$$ | 4: Apr | Donut Hole | $109.25 | $5.75 | $115.00 | $0.00 | $3,200.00 |
You entered the Coverage Gap (Donut Hole) in April. Your costs so far including the 2013 Coverage Gap Discount are $1,095.50. Your credit toward exiting the Coverage Gap is $1,210.50. This includes what you spent plus what the brand-name drug manufacturer (Mfgr) spent on your behalf. For plan year 2013, Non-LIS Medicare Beneficiaries get a 21% discount on generics and a 52.5% discount on brand-name drugs purchased in the Coverage Gap. Read Q&A about the Discount... | |||||||
$$ | 5: May | Donut Hole | $380.00 | $20.00 | $400.00 | $0.00 | $4,000.00 |
You are still in the Donut Hole. Your costs so far including the 2013 Coverage Gap Discount are $1,475.50. Your credit toward exiting the Coverage Gap is $1,990.50. | |||||||
$$ | 6: Jun | Donut Hole | $380.00 | $20.00 | $400.00 | $0.00 | $4,800.00 |
You are still in the Donut Hole. Your costs so far including the 2013 Coverage Gap Discount are $1,855.50. Your credit toward exiting the Coverage Gap is $2,770.50. | |||||||
$$ | 7: Jul | Donut Hole | $380.00 | $20.00 | $400.00 | $0.00 | $5,600.00 |
You are still in the Donut Hole. Your costs so far including the 2013 Coverage Gap Discount are $2,235.50. Your credit toward exiting the Coverage Gap is $3,550.50. | |||||||
$$ | 8: Aug | Donut Hole | $380.00 | $20.00 | $400.00 | $0.00 | $6,400.00 |
You are still in the Donut Hole. Your costs so far including the 2013 Coverage Gap Discount are $2,615.50. Your credit toward exiting the Coverage Gap is $4,330.50. | |||||||
$$ | 9: Sep | Donut Hole | $204.37 | $10.76 | $215.13 | $0.00 | $6,830.26 |
You are still in the Donut Hole. Your costs so far including the 2013 Coverage Gap Discount are $2,819.87. Your credit toward exiting the Coverage Gap is $4,750.00. | |||||||
$ | 9: Sep | Catastrophic Coverage | $18.49 | $55.46 | $0.00 | $295.79 | $7,200.00 |
You exited the Coverage Gap (Donut Hole) in September and are now in the catastrophic coverage. We have used 5% to calculate your costs.
The actual calculation is $2.65 for generics, $6.6 for brands or 5% whichever is higher. Your costs so far $2,838.36. | |||||||
$ | 10: Oct | Catastrophic Coverage | $40.00 | $120.00 | $0.00 | $640.00 | $8,000.00 |
You will remain in Catastrophic Coverage until the end of the year. Your costs so far $2,878.36. | |||||||
$ | 11: Nov | Catastrophic Coverage | $40.00 | $120.00 | $0.00 | $640.00 | $8,800.00 |
You will remain in Catastrophic Coverage until the end of the year. Your costs so far $2,918.36. | |||||||
$ | 12: Dec | Catastrophic Coverage | $40.00 | $120.00 | $0.00 | $640.00 | $9,600.00 |
You will remain in Catastrophic Coverage until the end of the year. Your costs so far $2,958.36. | |||||||
Summary |
Who Pays | Total Retail |
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You | Plan | Mfgr | Gov | ||||
Totals without premium: | $2,958.36 | $2,495.72 | $1,930.13 | $2,215.79 | $9,600.00 | ||
Notes: *Copayments do not influence when you will enter and leave the Donut Hole (which is based on plan’s negotiated retail drug costs). It will only affect your out-of-pocket costs. **For plan years 2011 to 2024, the chart values include the Donut Hole Discount. Read Q&A about the Discount. ***Beginning with plan year 2024, the Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | |||||||
Legend: | |||||||
$$$ | You are responsible for 100% of your prescription (Rx) costs. This occurs during the Initial Deductible phase of coverage. (Many plans do not have an initial deductible or exclude low-cost generic drugs from the deductible. ) It also occurred in the Coverage Gap (Donut Hole) unless your plan has Donut Hole coverage. | ||||||
$$ | You share your prescription (Rx) costs with your Medicare Part D plan provider. During the Initial Coverage Phase, you are responsible for 25% of your medication costs
(basic or standard plans) or a copayment on enhanced plans. In plan year 2013, your drug costs are also shared during the Coverage Gap. The plan pays 21% of your generic drug costs and the drug manufacturer pays 52.5% of your brand drug costs. Read Q&A about the Discount... |
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$ | You pay a small fraction of your prescription (Rx) costs. This occurs in Catastrophic Coverage. You pay 5% of your medication costs or $2.65 for generics or $6.6 for brand drugs (whichever is higher). |
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