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Calculate your Out-Of-Pocket Expenditure

Medicare set forth the following guidelines for 2020 Medicare Part D prescription drug plans, however, available plans may vary from these guidelines.

Monthly Premium - $35.00 to $37.00 Paid by the Medicare Beneficiary (See our Medicare Part D Plan Overview by State to review features and premiums of plans available in your state.)
Annual Deductible - $435 Paid by the Medicare Beneficiary
Cost of Prescriptions ($436 - $4020) -
25% Paid by the Medicare Beneficiary - 75% Paid by Medicare
Cost of Prescriptions ($4021 - $9038.75) -
100 % Paid by the Medicare Beneficiary - 0% Paid by Medicare
More than $6350 annual out-of-pocket threshold - The Medicare Beneficiary pays the greater of either 5% of the prescription drug costs or $3.6 for generic prescription drugs and $8.95 for brand-name prescription drugs. Medicare Part D pays the lesser of either: 95% of the prescription drug costs or the balance of the prescription drug costs.

We do have an online Cost calculator and Donut Hole estimator to Help

We provide different tools to help you estimate your Medicare Part D prescription drug spending: Our online Cost Calculator and our Donut Hole Calculator.
But remember:Retail drug costs can change throughout the plan year - as do your prescription needs - and the introduction of new generics or brand-name medications. In short, you cannot predict your Medicare plan spending with 100 percent accuracy, but you can calculate an estimate of your spending that will help you with budgeting for next year.

You can click on the links to calculate an estimate of your out-of-pocket expenditures with Medicare Part D prescription drug coverage.

Here is an example of how the out-of-pocket costs add-up.

If a Medicare beneficiary had prescription drug costs of $9038.75 per year, here is how much it would cost the Medicare Part D beneficiary personally or out-of-pocket:
Annual Deductible (or first $435 spent):-$435
25% of ($4020 - $435 = $3585):-$896.25
100% of ($9038.75 - $4020 = $5018.75):-$5018.75
Total Cost to Medicare Beneficiary (out-of-pocket):-$6350

Therefore, our Medicare beneficiary that had Prescription drug costs of $9038.75, would have approximately $6350 of out of pocket or personal costs per year.

What if our example Medicare beneficiary has Prescription drug costs of more than $9038.75?

Once our example Medicare Beneficiary has spent approximately $6350, the last paragraph of the guidelines goes into effect:

More than $6350 annual out-of-pocket threshold
  • The Medicare Beneficiary pays: the greater of either: (1) 5% of the Prescription Drug Costs or (2) $3.6 for generic Prescription Drugs / $8.95 for brand-name Prescription Drugs.
  • Medicare Pays: the lesser of either: (1) 95% of the Prescription Drug costs or (2) the balance of the Prescription Drug costs.

At this point in our example, the costs to the Medicare beneficiary will depend on the type/cost of prescription medication that is purchased. For example, if the Medicare beneficiary purchases non-generic Prescription drugs costing more than $8.95, the Medicare Beneficiary would need to pay 5% of the total costs.

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • 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.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. 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 area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • 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 medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.