2016 Part D Standard Plan Cost-Sharing*
September 11, 2015
|Part D Benefit Cost Periods||Cost and Who Pays||Beneficiary Pays (TrOOP)||Plan Pays||Total Amount Spent on Plan-Covered Drugs|
|Initial Deductible||Beneficiary pays 100%||Up to $360||$0||$360 (Amount spent on deductible, before ICP begins)|
|Initial Coverage Period (ICP)||Costs of covered drugs are shared: 25% by beneficiary, 75% by plan||Up to $737.50||$2,212.50||$2,950 (Amount spent during ICP, before Coverage Gap begins)|
|Discounts in 2016:
Costs of plan-covered drugs are shared:
Note about True Out-of-Pocket (TrOOP) costs:
Payments made by the plan during the Coverage Gap (42% on generics, 5% on brand-name drugs) do not count toward TrOOP
|Coverage Gap begins once beneficiary reaches the Initial Coverage Limit
$3,310 – Initial Coverage Limit (Total amount spent on any initial deductibe and during ICP)
Up to $3,752.50 (Total amount spent during Coverage Gap)
$7,062.50 (Total amount spent during ICP and Coverage Gap, before Catastrophic Benefit Period begins)
|Catastrophic Benefit Period||Costs of covered drugs are shared:
Beneficiary pays reduced copay/coinsurance; plan pays the difference
5% coinsurance OR $2.95 copay for generic, $7.40 copay for brand or non-preferred
|Any remaining portion of the negotiated drug price||Beneficiary will remain in the Catastrophic Benefit Period through December 31, 2016
Part D benefit will reset on January 1, 2017, starting again with a deductible
*Most Part D plans are not standard plans. This means calculating TrOOP costs during the initial deductible and ICP varies by plan.
Source 2016 Call Letter (pg. 37) at: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2016.pdf
Center for Benefits Access – National Council on Aging – Updated August 2015
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