Medicare Part D Benefit Parameters for Defined Standard Benefit
2006 through 2012 Comparison |
| Part D Standard Benefit Design Parameters: |
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
| Deductible - (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. |
$250 |
$265 |
$275 |
$295 |
$310 |
$310 |
$320 |
| 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) |
$2,250 |
$2,400 |
$2,510 |
$2,700 |
$2,830 |
$2,840 |
$2,930 |
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - Catastrophic Coverage starts after this point.
See note (1) below. |
$5,100.00 |
$5,451.25 |
$5,726.25 |
$6,153.75 |
$6,440.00
plus a
$250
rebate |
$6,447.50 (1)
plus a
50%
brand
& 7%
generic
discount |
$6,657.50 (1)
plus a
50%
brand
& 14%
generic
discount |
Out-of-Pocket Threshold - This is the Total Out-of-Pocket Costs including the Donut Hole.
2012 Example:
$320 (Deductible)
+(($2930-$320)*25%) (Initial Coverage)
+(($6657.5-$2930)*100%) (Cov. Gap)
= $4,700 (Maximum Out-Of-Pocket Cost prior to Catastrophic Coverage - excluding plan premium) |
$3,600
$ 250.00
$ 500.00
$2850.00
$3600.00 |
$3,850
$ 265.00
$ 533.75
$3051.25
$3850.00 |
$4,050
$ 275.00
$ 558.75
$3216.25
$4050.00 |
$4,350
$ 295.00
$ 601.25
$3453.75
$4350.00 |
$4,550
$ 310.00
$ 630.00
$3610.00
$4550.00 |
$4,550
$ 310.00
$ 632.50
$3607.50
$4550.00 |
$4,700
$ 320.00
$ 652.50
$3727.50
$4700.00 |
| Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2). |
|
|
|
|
|
$6,483.72 |
$6,730.39 |
| Catastrophic Coverage Benefit: |
Generic/Preferred
Multi-Source Drug |
$2.00 |
$2.15 |
$2.25 |
$2.40 |
$2.50 |
$2.50 |
$2.60 (4) |
| Other Drugs |
$5.00 |
$5.35 |
$5.60 |
$6.00 |
$6.30 |
$6.30 |
$6.50 (4) |
| Part D Full Benefit Dual Eligible (FBDE) Parameters: |
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
| Deductible: |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| Copayments for Institutionalized Beneficiaries |
$0.00 |
$0.00 |
$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 |
$1.00 |
$1.00 |
$1.05 |
$1.10 |
$1.10 |
$1.10 |
$1.10 |
| Other |
$3.00 |
$3.10 |
$3.10 |
$3.20 |
$3.30 |
$3.30 |
$3.30 |
Above Out-of-Pocket
Threshold |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| Over 100% FPL: |
| Up to Out-of-Pocket Threshold |
Generic/Preferred
Multi-Source Drug |
$2.00 |
$2.15 |
$2.25 |
$2.40 |
$2.50 |
$2.50 |
$2.60 |
| Other |
$5.00 |
$5.35 |
$5.60 |
$6.00 |
$6.30 |
$6.30 |
$6.50 |
Above Out-of-Pocket
Threshold |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| Part D Full Subsidy - Non Full Benefit Dual Eligible Full Subsidy Parameters: |
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
| Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and and resources < $6,940 (individuals) or < $10,410 (couples) (3) |
| Deductible: |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
Maximum Copayments up to Out-of-Pocket Threshold |
Generic/Preferred
Multi-Source Drug |
$2.00 |
$2.15 |
$2.25 |
$2.40 |
$2.50 |
$2.50 |
$2.60 |
| Other |
$5.00 |
$5.35 |
$5.60 |
$6.00 |
$6.30 |
$6.30 |
$6.50 |
Maximum Copay above
Out-of-Pocket
Threshold |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
| Partial Subsidy Parameters: |
2006 |
2007 |
2008 |
2009 |
2010 |
2011 |
2012 |
| Applied and income below 150% FPL and resources between $6,941-$11,570 (individuals) or $10,411-$23,120 (couples) (category code 4) (3) |
| Deductible |
$50.00 |
$53.00 |
$56.00 |
$60.00 |
$63.00 |
$63.00 |
$65.00 |
Coinsurance up to
Out-of-Pocket
Threshold |
15% |
15% |
15% |
15% |
15% |
15% |
15% |
| Maximum Copayments above Out-of-Pocket Threshold |
Generic/Preferred
Multi-Source Drug |
$2.00 |
$2.15 |
$2.25 |
$2.40 |
$2.50 |
$2.50 |
$2.60 |
| Other |
$5.00 |
$5.35 |
$5.60 |
$6.00 |
$6.30 |
$6.30 |
$6.50 |
| (1) Total Covered Part D Spending at Out-of-Pocket Threshold for Non-Applicable Beneficiaries - Beneficiaries who ARE entitled to an income-related subsidy under section 1860D-14(a) (LIS) |
| (2) Total Covered Part D Spending at Out-of-Pocket Threshold for Applicable Beneficiaries - Beneficiaries who are NOT entitled to an income-related subsidy under section 1860D-14(a) (NON-LIS) and do receive the coverage gap discount. For 2012, the weighted gap coinsurance factor is 98.082%. This is based on the 2010 PDEs (86.3% Brands & 13.7% Generics) |
| (3) The actual amount of resources allowable was updated in April 2012 for contract year 2012 and 2013. |
| (4) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2012, beneficiaries would be charged $2.60 for those generic or preferred multisource drugs with a retail price under $52 and 5% for those with a retail price greater than $52. As to Brand drugs, beneficiaries would pay $6.50 for those drugs with a retail price under $130 and 5% for those with a retail price over $130. |
