2016 Donut Hole Calculation Summary: | |
Summary of the annual retail cost of your drugs:
|
|
Percentage of Generic vs. Brand drug purchases used: | |
0% Generic / 100% Brand (not vaccine adjusted) | |
You will enter the Coverage Gap (Donut Hole): | in May |
You will exit the Coverage Gap (Donut Hole): | in October |
Your total annual Out-of-Pocket Costs without premium: | $2,992.00 |
2016 Donut Hole Calculation Details | |||||||
Month |
Plan Phase |
Who Pays | Total Retail |
||||
You | Plan | Mfgr | Gov | ||||
$$$ | 1: Jan | Deductible | $360.00 | $0.00 | $0.00 | $0.00 | $360.00 |
Your deductible is less than your Rx costs for the month, so here we will use the deductible of $360 and on the next line you will see your initial coverage costs for the remainder of this month. Your costs so far $360. | |||||||
$$ | 1: Jan | Initial Coverage | $110.00 | $330.00 | $0.00 | $0.00 | $800.00 |
You satisfied the remainder of your deductible ($360) earlier this month. Now, in the Initial Coverage phase, you pay 25% of the remaining Rx costs for the month ($440.00) (upto the initial coverage limit--ICL) and your plan pays 75%. Some plan offer copayments instead.* Your costs so far $470.00. | |||||||
$$ | 2: Feb | Initial Coverage | $200.00 | $600.00 | $0.00 | $0.00 | $1,600.00 |
You are in the Initial Coverage Phase. Your costs so far $670.00. | |||||||
$$ | 3: Mar | Initial Coverage | $200.00 | $600.00 | $0.00 | $0.00 | $2,400.00 |
You are in the Initial Coverage Phase. Your costs so far $870.00. | |||||||
$$ | 4: Apr | Initial Coverage | $200.00 | $600.00 | $0.00 | $0.00 | $3,200.00 |
You are in the Initial Coverage Phase. Your costs so far $1,070.00. | |||||||
$$ | 5: May | Initial Coverage | $27.50 | $82.50 | $0.00 | $0.00 | $3,310.00 |
You are in the Initial Coverage Phase. Your costs so far $1,097.50. | |||||||
$$ | 5: May | Donut Hole | $310.50 | $34.50 | $345.00 | $0.00 | $4,000.00 |
You entered the Coverage Gap (Donut Hole) in May. Your costs so far including the 2016 Coverage Gap Discount are $1,408.00. Your credit toward exiting the Coverage Gap is $1,753.00. This includes what you spent plus what the brand-name drug manufacturer (Mfgr) spent on your behalf. For plan year 2016, Non-LIS Medicare Beneficiaries get a 42% discount on generics and a 55% discount on brand-name drugs purchased in the Coverage Gap. Read Q&A about the Discount... | |||||||
$$ | 6: Jun | Donut Hole | $360.00 | $40.00 | $400.00 | $0.00 | $4,800.00 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $1,768.00. Your credit toward exiting the Coverage Gap is $2,513.00. | |||||||
$$ | 7: Jul | Donut Hole | $360.00 | $40.00 | $400.00 | $0.00 | $5,600.00 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,128.00. Your credit toward exiting the Coverage Gap is $3,273.00. | |||||||
$$ | 8: Aug | Donut Hole | $360.00 | $40.00 | $400.00 | $0.00 | $6,400.00 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,488.00. Your credit toward exiting the Coverage Gap is $4,033.00. | |||||||
$$ | 9: Sep | Donut Hole | $360.00 | $40.00 | $400.00 | $0.00 | $7,200.00 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,848.00. Your credit toward exiting the Coverage Gap is $4,793.00. | |||||||
$$ | 10: Oct | Donut Hole | $27.00 | $3.00 | $30.00 | $0.00 | $7,260.00 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,875.00. Your credit toward exiting the Coverage Gap is $4,850.00. | |||||||
$ | 10: Oct | Catastrophic Coverage | $37.00 | $111.00 | $0.00 | $592.00 | $8,000.00 |
You exited the Coverage Gap (Donut Hole) in October and are now in the catastrophic coverage. We have used 5% to calculate your costs.
The actual calculation is $2.95 for generics, $7.4 for brands or 5% whichever is higher. Your costs so far $2,912.00. | |||||||
$ | 11: Nov | Catastrophic Coverage | $40.00 | $120.00 | $0.00 | $640.00 | $8,800.00 |
You will remain in Catastrophic Coverage until the end of the year. Your costs so far $2,952.00. | |||||||
$ | 12: Dec | Catastrophic Coverage | $40.00 | $120.00 | $0.00 | $640.00 | $9,600.00 |
You will remain in Catastrophic Coverage until the end of the year. Your costs so far $2,992.00. | |||||||
Summary |
Who Pays | Total Retail |
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You | Plan | Mfgr | Gov | ||||
Totals without premium: | $2,992.00 | $2,761.00 | $1,975.00 | $1,872.00 | $9,600.00 | ||
Notes: *Copayments do not influence when you will enter and leave the Donut Hole (which is based on plan’s negotiated retail drug costs). It will only affect your out-of-pocket costs. **For plan years 2011 to 2024, the chart values include the Donut Hole Discount. Read Q&A about the Discount. ***Beginning with plan year 2024, the Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | |||||||
Legend: | |||||||
$$$ | You are responsible for 100% of your prescription (Rx) costs. This occurs during the Initial Deductible phase of coverage. (Many plans do not have an initial deductible or exclude low-cost generic drugs from the deductible. ) It also occurred in the Coverage Gap (Donut Hole) unless your plan has Donut Hole coverage. | ||||||
$$ | You share your prescription (Rx) costs with your Medicare Part D plan provider. During the Initial Coverage Phase, you are responsible for 25% of your medication costs
(basic or standard plans) or a copayment on enhanced plans. In plan year 2016, your drug costs are also shared during the Coverage Gap. The plan pays 42% of your generic drug costs and the drug manufacturer pays 55% of your brand drug costs. Read Q&A about the Discount... |
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$ | You pay a small fraction of your prescription (Rx) costs. This occurs in Catastrophic Coverage. You pay 5% of your medication costs or $2.95 for generics or $7.4 for brand drugs (whichever is higher). |
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