CMS Part D 2015 Standard Benefit Model Plan Details
Here are the highlights for the CMS defined Standard Benefit Plan changes from 2014 to 2015. The chart below shows the Standard Benefit design changes for plan years 2011, 2012, 2013, 2014 and 2015. This "Standard Benefit Plan" is the minimum allowable plan to be offered.
Initial Deductible: will be increased by $10 to $320 in 2015
Initial Coverage Limit: will increase from $2,850 in 2014 to $2,960 in 2015
Out-of-Pocket Threshold: will increase from $4,550 in 2014 to $4,700 in 2015
Coverage Gap (donut hole): begins once you reach your Medicare Part D plan’s initial coverage limit ($2,960 in 2015) and ends when you spend a total of $4,700 in 2015. In 2015, Part D enrollees will receive a 55% discount on the total cost of their brand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will still apply to getting out of the donut hole, however the additional 5% paid by your Medicare Part D plan will not count toward your TrOOP. Enrollees will pay a maximum of 65% co-pay on generic drugs purchased while in the coverage gap.
Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**: will increase to greater of 5% or $2.65 for generic or preferred drug that is a multi-source drug and the greater of 5% or $6.60 for all other drugs in 2015
Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $2.65 for generic or preferred drug that is a multi-source drug and $6.60 for all other drugs in 2015
Deductible - (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit.
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)
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - Catastrophic Coverage starts after this point.
See note (1) below.
Out-of-Pocket Threshold - This is the Total Out-of-Pocket Costs including the Donut Hole.
+(($2960-$320)*25%) (Initial Coverage)
+(($6680.00-$2960)*100%) (Cov. Gap)
= $4,700 (Maximum Out-Of-Pocket Cost prior to Catastrophic Coverage - excluding plan premium)
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2).
Applied and income below 150% FPL and resources between $8,581-$13,300 (individuals) or $13,621-$26,580 (couples) (category code 4) (4)
Coinsurance up to Out-of-Pocket Threshold
Maximum Copayments above Out-of-Pocket Threshold
Generic/Preferred Multi-Source Drug
(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 2015, the weighted gap coinsurance factor is 90.693%. This is based on the 2013 PDEs (85.9% Brands & 14.1% Generics)
(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2015, beneficiaries would be charged $2.65 for those generic or preferred multisource drugs with a retail price under $53 and 5% for those with a retail price greater than $53. As to Brand drugs, beneficiaries would pay $6.60 for those drugs with a retail price under $132 and 5% for those with a retail price over $132.
(4) The actual amount of resources allowable may be updated for contract year 2015.
CMS Proposed Change: New criteria for drug categories or classes of clinical concern not implemented
This proposed change has not been finalized for implementation in 2015.
In the first year of the Medicare prescription drug benefit, CMS implemented a policy that required all Part D plans to include on their formularies "all or substantially all" Part D drugs within six drug classes—antineoplastics, anticonvulsants, antiretrovirals, antipsychotics, antidepressants, and immunosuppressants. Under the proposed criteria, CMS would require formulary inclusion of all drugs within the antineoplastic, anticonvulsant, and antiretroviral drug classes (subject to proposed exceptions), but would no longer require all drugs from the antidepressant and immunosuppressant drug classes to be on all Part D formularies. Although antipsychotics do not meet the criteria, they will remain protected at least through 2015 while CMS evaluates additional considerations and the need for any other formulary exceptions.
In a March 10th 2014 letter, CMS stated " we [CMS] heard concerns about the proposals to lift the protected class definition of three drug classes, to set standards on Medicare Part D plans’ requirements to participate in preferred pharmacy networks, to reduce the number of Part D plans a sponsor may offer, and clarifications to the non-interference provisions. Given the complexities of these issues and stakeholder input, we [CMS] do not plan to finalize these proposals at this time. We [CMS] will engage in further stakeholder input before advancing some or all of the changes in these areas in the future years."
CMS Proposed Change: Increased competition not implemented
This proposed change will not be implemented for 2015. Proposal in the 2015 Advanced Notice:
This rule proposes to revise the definition of negotiated prices to require all price concessions from pharmacies to be reflected in negotiated prices. The proposed rule would provide greater cost savings for beneficiaries in return for offering preferred cost sharing so that sponsors cannot incentivize use of selected pharmacies, including the sponsors’ own related-party pharmacies that charge higher rates than their competitors.
Also, CMS may request that Part D plans increase the number of pharmacies offering preferred, or lower, cost sharing as CMS is concerned that some plans that offer preferred cost sharing do not provide beneficiaries with sufficient access to the lower cost sharing at select network pharmacies. The intent of this policy will be to ensure that beneficiaries are not misled into enrolling in a plan only to discover that they do not have meaningful access to the advertised lower cost sharing.
From the 2015 Announcement:
Although we [CMS] are not adopting any network adequacy standards at this time, sponsors should be aware that we are continuing to monitor beneficiary access to preferred cost sharing in plans that purport to offer it. For the 2014 and 2015 plan years, we [CMS] will continue to review the retail networks of plans offering preferred cost sharing and will continue to take appropriate action regarding any plan whose network of pharmacies offering preferred cost sharing appears to offer too little meaningful access to the preferred cost sharing. For instance, a stand-alone PDP that offers preferred cost sharing at only seven pharmacies in a PDP region may be asked to increase the number of pharmacies offering preferred cost sharing or to restructure its benefit design during the bid negotiation process. The intent of these negotiations will be to ensure that beneficiaries are not misled into enrolling in a plan only to discover that they do not have meaningful access to the advertised lower cost sharing.
We [CMS] note that beginning in 2015, we [CMS] will no longer use the terms "preferred" and "non-preferred" to describe network pharmacies, but rather will describe such pharmacies as offering standard or preferred cost-sharing.
CMS Proposed Change: Improved Notification for Beneficiaries Regarding Changes in Medicare Advantage Plan Networks Approved
Proposal in the 2015 Advanced Notice: The call letter identifies as a best practice greater notification to enrollees regarding any changes to provider networks and indicates CMS’ intention to consider rulemaking that would broaden its authority to limit such changes to certain times during the year.
From the 2015 Announcement:
Beginning in CY 2015, we [CMS] will require MAOs [Medicare Advantage Organizations] to notify CMS when they are planning network changes that the MAO deems significant and CMS will determine, after consultation with the MAO, whether the planned change requires certain additional actions on the part of the MAO in order for the organization’s network to continue to meet Medicare standards.
We [CMS] intend to take appropriate compliance action against an MAO that fails to notify CMS of network changes that we [CMS] ultimately deem significant. Therefore, we [CMS] expect MAOs to take a conservative approach in determining whether a network change is significant and notify CMS if there is any doubt as to whether the planned contract termination(s) represent significant change to the network.
CMS Proposed Change for 2016: More meaningful plan choices not finalized
This proposed change has not been finalized. In order to ensure that beneficiaries have better access to health plan services with meaningfully different benefits and transparent costs, and because the Affordable Care Act’s closing of the "donut hole" has reduced the need for plans offering enhanced benefits, CMS proposes that Prescription Drug Plans Sponsors offer no more than two Part D plans in the same service area. This provision would not be effective until 2016. The proposed rule would also prohibit MA plans from offering new plans that simply replace plans CMS has required to be terminated or consolidated due to low enrollment.
2015 Federal Poverty Level Guidelines: LIS Qualification
The 2015 Federal Poverty Level (FPL) Guidelines determine the income level requirements for people applying for the Medicare Part D Low Income Subsidy (LIS) program, also known as the "Extra Help" program. For the remainder of 2015, if your income is below 135% of the FPL ($15,889.50 if you are single or $21,505.50 for married couples), you could qualify for the full Low Income Subsidy (resource limits also apply - see chart above). Even if you don’t qualify for full LIS benefits, you could be eligible for partial LIS benefits if your income level is at or below 150% FPL (resource limits also apply - see chart above). Remember, the LIS subsidy helps to pay both your monthly plan premiums and drug costs.
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Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.
Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
Limitations, copayments, and restrictions may apply.
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However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service
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When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare.
Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits
money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible.
The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll
during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the
Beneficiaries can appoint a representative by submitting CMS Form-1696.