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2010 Medicare Part D Program Information

Below are the details of the 2010 Standard Benefit Model Plan.

:: Read Questions and Answers about the 2010 $250 Medicare Part D Rebate.

:: CMS Part D 2010 Standard Benefit Model Plan Details
:: Important Medicare Part D Dates for 2009-2010
:: Additional Proposed Changes for 2010

CMS Part D 2010 Standard Benefit Model Plan Details

Here are the highlights for the Centers for Medicare and Medicaid Services (CMS) defined Standard Benefit Plans for 2006, 2007, 2008, 2009 and 2010. This "Standard Benefit Plan" is the minimum allowable plan to be offered. The details of the 2010 plan will not be released until mid-April 2009. As we learn details, they will be added to the highlights and chart below.
  • Initial Deductible:
    from $295 in 2009 to $310* in 2010
  • Initial Coverage Limit:
    from $2,700 in 2009 to $2,830* in 2010
  • Out-of-Pocket Threshold:
    from $4,350 in 2009 to $4,550* in 2010
  • Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit:
    from $2.40 for generics and $6.00 for other drugs in 2009 to $2.50 for generic or preferred drug that is a multi-source drug and $6.30* for all other drugs in 2010
  • Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees:
    from $2.40 for generics and $6.00 for other drugs in 2009 to $2.50 for generic or preferred drug that is a multi-source drug and $6.30* for all other drugs in 2010
                                Click here to see a comparison of plan parameters for all years since 2006

Medicare Part D Benefit Parameters for Defined Standard Benefit
2006 through 2010 Comparison
Part D Standard Benefit Design Parameters: 2010* 2009 2008 2007 2006
Deductible - (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. $310 $295 $275 $265 $250
Initial Coverage Limit - Coverage Gap (Donut Hole) begins at this point. (The Beneficiary pays 100% of their prescription costs up to the Out-of-Pocket Threshold) $2,830 $2,700 $2,510 $2,400 $2,250
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - Catastrophic Coverage starts after this point.  $6,440.00

plus a
$250
rebate
 
 $6,153.75   $5,726.25   $5,451.25   $5,100.00 
Out-of-Pocket Threshold - This is the Total Out-of-Pocket Costs including the Donut Hole.
2010 Example:
   $310 (Deductible)
+(($2830-$310)*25%) (Initial Coverage)
+(($6440-$2830)*100%) (Cov. Gap)
= $4,500 (Maximum Out-Of-Pocket Cost prior to Catastrophic Coverage - excluding plan premium)
$4,550




 $ 310.00
$ 630.00

$3610.00

$4550.00
$4,350




 $ 295.00
$ 601.25

$3453.75

$4350.00
$4,050




 $ 275.00
$ 558.75

$3216.25

$4050.00
$3,850




 $ 265.00
$ 533.75

$3051.25

$3850.00
$3,600




 $ 250.00
$ 500.00

$2850.00

$3600.00
Catastrophic Coverage Benefit:
    Generic/Preferred
    Multi-Source Drug
$2.50 $2.40 $2.25 $2.15 $2.00
    Other Drugs $6.30 $6.00 $5.60 $5.35 $5.00
Part D Full Benefit Dual Eligible Parameters: 2010* 2009 2008 2007 2006
Copayments for Institutionalized Beneficiaries $0.00 $0.00 $0.00 $0.00 $0.00
Maximum Copayments for Non-Institutionalized Beneficiaries
    Up to or at 100% FPL:
        Up to Out-of-Pocket Threshold
            Generic/Preferred
            Multi-Source Drug
$1.10 $1.10 $1.05 $1.00 $1.00
            Other $3.30 $3.20 $3.10 $3.10 $3.00
        Above Out-of-Pocket
            Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
    Over 100% FPL:
        Up to Out-of-Pocket Threshold
            Generic/Preferred
            Multi-Source Drug
$2.50 $2.40 $2.25 $2.15 $2.00
            Other $6.30 $6.00 $5.60 $5.35 $5.00
        Above Out-of-Pocket
            Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
Part D Non-Full Benefit Dual Eligible Full Subsidy Parameters: 2010* 2009 2008 2007 2006
Resources < $6,600 (individuals) or < $9,910 (couples)*
    Maximum Copayments up to Out-of-Pocket Threshold
        Generic/Preferred
        Multi-Source Drug
$2.50 $2.40 $2.25 $2.15 $2.00
        Other $6.30 $6.00 $5.60 $5.35 $5.00
    Maximum Copay above
    Out-of-Pocket Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
Resources between $6,600-$11,010 (individuals) or $9,910-$22,010 (couples)*
    Deductible $63.00 $60.00 $56.00 $53.00 $50.00
    Coinsurance up to
    Out-of-Pocket Threshold
15% 15% 15% 15% 15%
    Maximum Copayments above Out-of-Pocket Threshold
        Generic/Preferred
        Multi-Source Drug
$2.50 $2.40 $2.25 $2.15 $2.00
        Other $6.30 $6.00 $5.60 $5.35 $5.00
Part D Non-Full Benefit Dual Eligible Partial Subsidy Parameters: 2010* 2009 2008 2007 2006
    Deductible $63.00 $60.00 $56.00 $53.00 $50.00
    Coinsurance up to
    Out-of-Pocket Threshold
15% 15% 15% 15% 15%
    Maximum Copayments above Out-of-Pocket Threshold
        Generic/Preferred
        Multi-Source Drug
$2.50 $2.40 $2.25 $2.15 $2.00
        Other $6.30 $6.00 $5.60 $5.35 $5.00
* The actual amount of resources allowable will be updated for contract year 2010.


:: Goto the 2011 Medicare Part D Outlook
:: Read Questions and Answers about the 2010 $250 Medicare Part D Rebate.
:: Click here to see a comparison of plan parameters for all years since 2006

* Notes, on April 6, 2009 CMS released finalized parameters for the 2010 Prescription Drug plans. CMS notes, "Updating the parameters helps ensure that the government's share of the Part D costs remains constant over time. The annual percentage increase in average per capita Part D spending -- used to update the deductible, initial coverage limit, and out-of-pocket threshold for the defined standard benefit for 2010 -- is 4.66 percent. The annual percentage increase in the Consumer Price Index -- used to update the 2010 maximum copayments below the out-of-pocket threshold for certain dual eligible enrollees -- is approximately 2.65 percent. CMS revised these percentages to correct calculation errors identified following release of the Advance Notice."
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Important Medicare Part D Dates for 2009-2010

  • October 1, 2009:
    Medicare Part D Prescription Drug plan Marketing Activities can begin - At this time you will be able to once again gather information and evaluate the various Part D plan alternatives.
  • Please note, no enrollments may be accepted before November 15, 2009.
  • November 15 to December 31, 2009:
    Annual Coordinated Election Period - Here is your chance to join a Medicare Part D plan for 2010. If you already have a Medicare Part D plan, this is your time to look back over 2009 and make another decision for your 2010 coverage. Should you stay with your existing coverage or make a change? Here is your opportunity to decide. If you make no decision, you will remain in the same plan as you elected in 2009. There is no enrollment required to renew your present coverage. Don't forget the previous years! People who waited until the end of December also waited into January for the arrival of their Welcome Information. Bottom Line: Don't wait until the end of December to make your enrollment decision. (If you do not enroll during this period, your next chance for coverage is January 2011.)
  • January 1, 2010:
    Your 2010 Medicare Part D plan becomes effective and you will be able to begin using your Part D benefits.
  • January 1 to March 31, 2010:
    Open Enrollment Period (or OEP) - This special period is available for those people who enrolled into a Medicare Advantage Plan with Prescription Drug coverage (MA-PDs) and now wish to disenroll back to original Medicare coverage and a Prescription Drug Plan. As noted by CMS: "PDPs must accept enrollments for individuals enrolled in a MA-PD plan and who choose to elect Original Medicare during the MA OEP that occurs from January 1, 2010 through March 31, 2010. Since MA rules require these individuals to maintain prescription drug coverage, they MUST enroll in a PDP to accompany Original Medicare. This OEP allows MA-PD enrollees to enroll in a PDP and is limited to 1 enrollment."

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Additional Proposed Changes for 2010

Some of the proposed 2010 changes in the Medicare Part D Prescription Drug Program are as follows:
  • Formulary Drugs - Beginning January 1, 2010, CMS proposes rejecting the inclusion of drugs on a formulary if the drug's national drug code (NDC) is one for which the FDA is unable to provide regulatory status determinations through their regular processes. Specifically, CMS is exploring the feasibility of establishing prescription drug event (PDE) submission edits based on a comparison of commercial databases that CMS uses to evaluate PDEs with information about drug products posted to FDA's NDC Directory. This comparison would help highlight NDCs for which it has not been affirmatively established that the product meets the statutory definition of covered Part D drug. CMS believes that it is best practice for Part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a Part D drug coverage determination.

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  • Specialty Tier Threshold - For contract year 2010, CMS will maintain the $600 threshold for drugs on the specialty tier. Thus, only Part D drugs with negotiated prices that exceed $600 per month may be placed in the specialty tier.

  • Transition Notices in Long Term Care Settings - For contract year 2010, CMS is permitting Part D sponsors the option of sending required transition fill notices to network long term care pharmacies. In Lieu of sending enrollees residing in LTC facilities a model transition notice via U.S. mail within 3 business days of the transition fill, Part D sponsors may elect to send the beneficiary transition notice to the LTC pharmacy serving the beneficiary's LTC facility. The LTC pharmacy must then ensure delivery of the notice to the beneficiary within 3 business days of the fill.

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  • Utilization Management (Prior Authorization and Step-Therapy - Part D sponsors must post submitted step-therapy and prior authorization requirements on their plan websites. Part D sponsors will need to ensure that all utilization management criteria submitted to CMS, including step therapy criteria, are available on their formulary websites for display by November 15, 2009.

  • Medication Therapy Management Program Requirements - CMS stated that MTM programs must evolve and become a cornerstone of the Medicare Prescription Drug Benefit. MDM program target beneficiaries who have multiple chronic diseases, are taking multiple Part D drugs, and are likely to incur annual costs for covered Part D drugs that exceed a predetermined level a specified by the CMS Secretary. The existing threshold is $4,000 and will be lowered to $3000 for 2010. Plans will evaluate beneficiaries at least on a quarterly basis for automatic inclusion in the program. The beneficiary may choose to opt-out of the MTM program. The services provided in the MTM program, at a minimum, include: an annual comprehensive medication review (CMR), no less than quarterly targeted medication reviews, offer interventions targeted to providers to resolve medication-related problems or other opportunities to optimize the targeted beneficiary's medication use.

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  • Reference-Based Pricing - Under these programs, sponsors may require enrollees to pay a defined cost-sharing amount plus supplemental cost-sharing based on the differential in cost between the drug being dispensed and a lower-cost preferred alternative such as a generic equivalent. In contract year 2009, fewer than 10% of Part D contracts used reference-based pricing. Given the complexity of reference-based pricing formulas, it is very difficult to accurately convey the extent of expected out-of-pocket spending for formulary drugs subject to reference-based pricing. For this reason, CMS has been unable to have the Medicare Prescription Drug Plan Finder (MPDPF) calculate correct pricing for drugs subject to reference-based pricing, which may distort projections of out-of-pocket expenditures for some beneficiaries and significantly affect their ability to compare cost-sharing obligations under different plans and choose the plan that best meets their needs.

    Based on CMS' experience and the increased complexity, CMS has observed with these programs, CMS will eliminate the option of reference-based pricing in the Part D Prescription Benefit Program (PBP) beginning in CY 2010. The basis for this decision is CMS' belief that reference-based pricing may be inherently misleading to beneficiaries and inconsistent with their goal of improving transparency with regard to expected beneficiary cost-sharing under the Part D program.

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  • Reassignment of Low-Income Subsidy Eligible Individuals - In Fall 2009, CMS will reassign certain low-income subsidy (LIS) eligible beneficiaries from PDPs with premiums that exceed the LIS benchmark in 2010 to PDPs with premiums at or below the benchmark, effective January 1, 2010. They will continue to provide mailing to affected individuals. CMS will also work with plans that are losing members to identify appropriate ways to reach out to these members to explain how they can remain in their current plan and what their premium liability will be if they choose to do so.

  • Retroactive Auto-Enrollment of Full Benefit Dual Eligible Individuals - Beginning on January 1, 2010, CMS intends to implement a demonstration in which it will assign new full benefit dual eligible individuals with retroactive coverage to a single contractor for those retroactive periods. CMS will conduct a competitive solicitation to select this contractor early in 2009. CMS will continue to randomly assign these individuals to qualifying PDPs on a prospective basis.

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Last updated on: 02/18/2014

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