2025-2006 Medicare Part D Standard Benefit Model Plan Parameters
Below is a comparison of the Standard Benefit Model Plan parameters as released by The Centers for Medicare and Medicaid Services (CMS) for the plan years 2025 through 2006.Medicare Part D Benefit Parameters for Defined Standard Benefit |
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| Part D Standard Benefit Design Parameters | 2025* | 2024* | 2023 | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 |
| Deductible - In most situations, the beneficiary pays 100% of their drug costs until the deductible is met. | $590 | $545 | $505 | $480 | $445 | $435 | $415 | $405 | $400 | $360 | $320 | $310 | $325 | $320 | $310 | $310 | $295 | $275 | $265 | $250 |
| Initial Coverage Limit (ICL) - Beginning with plan year 2025, the ICL is eliminated. Pre-2025, prior to reaching the ICL the beneficiary paid 25% of their drug costs and once the ICL was reached, the Coverage Gap (Donut Hole) began. | Not Applicable | $5,030 | $4,660 | $4,430 | $4,130 | $4,020 | $3,820 | $3,750 | $3,700 | $3,310 | $2,960 | $2,850 | $2,970 | $2,930 | $2,840 | $2,830 | $2,700 | $2,510 | $2,400 | $2,250 |
| Out-of-Pocket Threshold (OOP threshold or RxMOOP) -
The Catastrophic Coverage phase begins
(and prior to 2025, the Coverage Gap ended
when Total Out-of-Pocket (TrOOP) costs exceed this value. Beginning with plan year 2025, the Coverage Gap phase is eliminated. |
$2,000 | $8,000 | $7,400 | $7,050 | $6,550 | $6,350 | $5,100 | $5,000 | $4,950 | $4,850 | $4,700 | $4,550 | $4,750 | $4,700 | $4,550 | $4,550 | $4,350 | $4,050 | $3,850 | $3,600 |
| Total covered Part D drug out-of-pocket spending before entering Catastrophic Coverage (pre-2025 exiting the Coverage Gap) - (LIS). See note (1) below. | $6,230 | $11,477.39 | $10,516.25 | $10,012.50 | $9,313.75 | $9,038.75 | $7,653.75 | $7,508.75 | $7,425.00 | $7,062.50 | $6,680.00 | $6,455.00 | $6,733.75 | $6,657.50 | $6,447.50 | $6,440.00 plus a $250 rebate |
$6,153.75 | $5,726.25 | $5,451.25 | $5,100.00 |
| Total estimated Part D drug out-of-pocket spending before entering Catastrophic Coverage (pre-2025 exiting the Coverage Gap) - (non-LIS). See note (2) below. | $6,230 | $12,447.11 plus a 75% discount on all formulary drugs |
$11,206.28 plus a 75% discount on all formulary drugs |
$10,690.20 plus a 75% discount on all formulary drugs |
$10,048.39 plus a 75% discount on all formulary drugs |
$9,719.38 plus a 75% discount on all formulary drugs |
$8,139.54 plus a 75% brand discount |
$8,417.60 plus a 65% brand discount |
$8,071.16 plus a 60% brand discount |
$7,515.22 plus a 55% brand discount |
$7,061.76 plus a 55% brand discount |
$6,690.77 plus a 52.50% brand discount |
$6,954.52 plus a 52.50% brand discount |
$6,730.39 plus a 50% brand discount |
$6,483.72 plus a 50% brand discount |
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| Catastrophic Coverage Benefit:
Beginning with plan year 2024, beneficiary cost-sharing in the Catastrophic Coverage stage of the Medicare Part D coverage is eliminated - and shown below as not applicable. From 2006 through 2023 the Catastrophic Coverage cost-sharing was the greater of 5% or the values shown below. |
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| Generic/Preferred Multi-Source Drug | Not Applicable | Not Applicable | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| Other Drugs | Not Applicable | Not Applicable | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
Parameters for Medicare Beneficiaries qualifying for the Low-Income Subsidy (LIS) (Extra Help) program |
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| Part D Full Benefit Dual Eligible (FBDE) Beneficiaries Parameters See note (3): | ||||||||||||||||||||
| 2025 | 2024 | 2023 | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | |
| • Deductible | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| • Copayments for Institutionalized Beneficiaries [category code 3] | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| • Copayments for Beneficiaries Receiving Home and Community-Based Services [category code 3] see note (4) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| • Maximum Copayments for FBDE Non-Institutionalized Beneficiaries Up to or at 100% FPL [category code 2]: | ||||||||||||||||||||
| • Up to Out-of-Pocket Threshold | ||||||||||||||||||||
| - Generic / Preferred Multi-Source Drug | $1.60 | $1.55 | $1.45 | $1.35 | $1.30 | $1.30 | $1.25 | $1.25 | $1.20 | $1.20 | $1.20 | $1.20 | $1.15 | $1.10 | $1.10 | $1.10 | $1.10 | $1.05 | $1.00 | $1.00 |
| - Other Drugs | $4.80 | $4.60 | $4.30 | $4.00 | $4.00 | $3.90 | $3.80 | $3.70 | $3.70 | $3.60 | $3.60 | $3.60 | $3.50 | $3.30 | $3.30 | $3.30 | $3.20 | $3.10 | $3.10 | $3.00 |
| • Above Out-of-Pocket Threshold | Not Applicable | Not Applicable | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| • Maximum Copayments for FBDE Non-Institutionalized Beneficiaries Between 100% and 150% FPL [category code 1]: | ||||||||||||||||||||
| • Up to Out-of-Pocket Threshold | ||||||||||||||||||||
| - Generic / Preferred Multi-Source Drug | $4.90 | $4.50 | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| - Other Drugs | $12.15 | $11.20 | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
| • Above Out-of-Pocket Threshold | Not Applicable | Not Applicable | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Part D Full-Subsidy - Non-FBDE Beneficiary Parameters: | ||||||||||||||||||||
| 2025 | 2024 | 2023 | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | |
| Applied or eligible for QMB/SLMB/QI or SSI, income at or below
150% FPL and
resources ≤ $17,220 (individuals in 2024) or ≤ $34,360 (couples in 2024) [category code 1] see note (5).
See resources for prior years. Prior to 2024, the full-subsidy income limit was ≤ 135% FPL. | ||||||||||||||||||||
| • Deductible | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $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 | $4.90 | $4.50 | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| - Other Drugs | $12.15 | $11.20 | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
| • Maximum Copay above Out-of-Pocket Threshold | Not Applicable | Not Applicable | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Partial-Subsidy Parameters (Partial-LIS was eliminated January 1, 2024, when Full-LIS was expanded to include former partial-LIS): | ||||||||||||||||||||
| 2025 | 2024 | 2023 | 2022 | 2021 | 2020 | 2019 | 2018 | 2017 | 2016 | 2015 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | |
| Prior to 2024, Partial-LIS included beneficiaries who have applied for benefits and have income below 150% FPL and limited resources [category code 4] (5). See resources for prior years. | ||||||||||||||||||||
| • Deductible | Not Applicable | Not Applicable | $104.00 | $99.00 | $92.00 | $89.00 | $85.00 | $83.00 | $82.00 | $74.00 | $66.00 | $63.00 | $66.00 | $65.00 | $63.00 | $63.00 | $60.00 | $56.00 | $53.00 | $50.00 |
| • Coinsurance up to Out-of-Pocket Threshold | Not Applicable | Not Applicable | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% | 15% |
| • Maximum Copayments above Out-of-Pocket Threshold | ||||||||||||||||||||
| - Generic / Preferred Multi-Source Drug | Not Applicable | Not Applicable | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | $3.35 | $3.30 | $2.95 | $2.65 | $2.55 | $2.65 | $2.60 | $2.50 | $2.50 | $2.40 | $2.25 | $2.15 | $2.00 |
| - Other Drugs | Not Applicable | Not Applicable | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | $8.35 | $8.25 | $7.40 | $6.60 | $6.35 | $6.60 | $6.50 | $6.30 | $6.30 | $6.00 | $5.60 | $5.35 | $5.00 |
| *These parameters reflect additional plan coverage required for covered insulin products under section 1860D-2(b)(9) of the Act, as added by section 11406 of the IRA, and ACIP-recommended vaccines under section 1860D-2(b)(8) of the Act, as added by section 11401 of the IRA. | ||||||||||||||||||||
| (1) For a beneficiary who is not considered an "applicable beneficiary" (i.e. LIS-eligible), as defined at section 1860D-14A(g)(1) of the Social Security Act, and is not eligible for the Medicare Coverage Gap Discount Program, this is the amount of total drug spending required to reach the OOP threshold in the defined standard benefit. Medicare notes, that in 2024, "There was a 7 percent adjustment for the estimated total covered Part D spending at catastrophic for non-applicable beneficiaries, because beneficiaries take a longer time to reach the catastrophic phase threshold when they pay less cost sharing for insulins and vaccines (no more than $35 copay per month's supply of insulin and $0 copay on ACIP-recommended adult vaccines) under the 2024 defined standard benefit." | ||||||||||||||||||||
| (2) For a beneficiary who is an "applicable beneficiary" (non-LIS), as defined at section 1860D-14A(g)(1) of the Act, and is eligible for the Medicare Coverage Gap Discount Program, this is the estimated average amount of total drug spending required to reach the OOP threshold in the defined standard benefit. Medicare notes, that in 2024, "there was a 9 percent adjustment for the estimated total covered Part D spending at catastrophic for applicable beneficiaries, because beneficiaries take a longer time to reach the catastrophic phase threshold when they pay less cost sharing for insulins and vaccines (no more than $35 copay per month's supply of insulin and $0 copay on ACIP-recommended adult vaccines) under the 2024 defined standard benefit". | ||||||||||||||||||||
(3) The LIS eligibility categories and corresponding cost-sharing benefits are sometimes
referred to using category codes as follows:
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| (4) Per section 1860D-14(a)(1)(D)(i) of the Act, full-benefit dually eligible beneficiaries who are receiving home and community-based services qualify for zero cost sharing if the individuals (or couple) would have been institutionalized otherwise. | ||||||||||||||||||||
| (5) The resource limits for CY 2025 will be provided via the annual HPMS memo entitled "2025 Resource and Cost-Sharing Limits for Low-Income Subsidy (LIS)" that is expected to be released during the usual timeframe after the September 2024 CPI has been made available by the Bureau of Labor Statistics. Additionally, these amounts include $1,500 per person for burial expenses. Also, beneficiaries that would have been eligible for the partial LIS benefit had the IRA not been enacted will be eligible for the full LIS benefit if they meet either of the resource standard described at sections 1860D-14(a)(3)(D) or (E) of the Act. | ||||||||||||||||||||
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