Preview – 2017 Part D Standard Benefit & Other Threshold Amounts

Annual Deductible Maximum

$400

Initial Coverage Period

Cost sharing during this period may be a flat 25% co-insurance OR the plan may have a tiered system of co-pays and co-insurance that is actuarially equivalent to 25%

Initial Coverage Limit

(Once the member AND the plan have spent this amount, the member enters the Donut Hole)

$3,700

Donut Hole

 During this period the member pays reduced costs for both generic and brand name drugs.  On brand name drugs the member receives a 50% manufacturer discount and a further 10% subsidy from Medicare.  On generic drugs the member receives a 49% subsidy from Medicare.  The full cost of brand name drugs, minus the subsidy, counts toward TROOP (90%); the price paid for generic drugs (51%) counts also counts toward TROOP.

Catastrophic Coverage Threshold

Catastrophic coverage begins when the member’s true out-of-pocket (TROOP) costs equals this amount.

$4,950

Total member spending before Catastrophic Coverage

$7,425

Cost sharing during Catastrophic Coverage

$3.30 (generics) / $8.25 (brand name)

OR 5%, whichever is greater

Generics Co-pay

Brand Name Co-Pay

Deductible

Institutionalized FBDE or on HCBS waiver program

$0

$0

$0

FBDE at or below 100% FPL

$1.20

$3.70

$0

FBDE over 100% FPL

$3.30

$8.25

$0

Full Subsidy (up to 135% FPL)

$3.30

$8.25

$0

Partial Subsidy (up to 150% FPL)

15%

15%

$82