2016 Donut Hole Calculation Summary: | |
Summary of the annual retail cost of your drugs:
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Percentage of Generic vs. Brand drug purchases used: | |
12.10% Generic / 87.90% Brand (not vaccine adjusted) | |
You will enter the Coverage Gap (Donut Hole): | in June |
You will exit the Coverage Gap (Donut Hole): | in December |
Your total annual Out-of-Pocket Costs without premium: | $3,031.11 |
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 | $66.57 | $199.70 | $0.00 | $0.00 | $626.27 |
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 ($266.27) (upto the initial coverage limit--ICL) and your plan pays 75%. Some plan offer copayments instead.* Your costs so far $426.57. | |||||||
$$ | 2: Feb | Initial Coverage | $156.57 | $469.70 | $0.00 | $0.00 | $1,252.54 |
You are in the Initial Coverage Phase. Your costs so far $583.13. | |||||||
$$ | 3: Mar | Initial Coverage | $156.57 | $469.70 | $0.00 | $0.00 | $1,878.80 |
You are in the Initial Coverage Phase. Your costs so far $739.70. | |||||||
$$ | 4: Apr | Initial Coverage | $156.57 | $469.70 | $0.00 | $0.00 | $2,505.07 |
You are in the Initial Coverage Phase. Your costs so far $896.27. | |||||||
$$ | 5: May | Initial Coverage | $156.57 | $469.70 | $0.00 | $0.00 | $3,131.34 |
You are in the Initial Coverage Phase. Your costs so far $1,052.84. | |||||||
$$ | 6: Jun | Initial Coverage | $44.66 | $133.99 | $0.00 | $0.00 | $3,310.00 |
You are in the Initial Coverage Phase. Your costs so far $1,097.50. | |||||||
$$ | 6: Jun | Donut Hole | $208.47 | $42.42 | $196.72 | $0.00 | $3,757.61 |
You entered the Coverage Gap (Donut Hole) in June. Your costs so far including the 2016 Coverage Gap Discount are $1,305.97. Your credit toward exiting the Coverage Gap is $1,502.69. 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... | |||||||
$$ | 7: Jul | Donut Hole | $291.67 | $59.35 | $275.24 | $0.00 | $4,383.88 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $1,597.64. Your credit toward exiting the Coverage Gap is $2,069.61. | |||||||
$$ | 8: Aug | Donut Hole | $291.67 | $59.35 | $275.24 | $0.00 | $5,010.15 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $1,889.31. Your credit toward exiting the Coverage Gap is $2,636.52. | |||||||
$$ | 9: Sep | Donut Hole | $291.67 | $59.35 | $275.24 | $0.00 | $5,636.42 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,180.98. Your credit toward exiting the Coverage Gap is $3,203.44. | |||||||
$$ | 10: Oct | Donut Hole | $291.67 | $59.35 | $275.24 | $0.00 | $6,262.68 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,472.65. Your credit toward exiting the Coverage Gap is $3,770.36. | |||||||
$$ | 11: Nov | Donut Hole | $291.67 | $59.35 | $275.24 | $0.00 | $6,888.95 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $2,764.33. Your credit toward exiting the Coverage Gap is $4,337.27. | |||||||
$$ | 12: Dec | Donut Hole | $263.79 | $53.68 | $248.93 | $0.00 | $7,455.36 |
You are still in the Donut Hole. Your costs so far including the 2016 Coverage Gap Discount are $3,028.12. Your credit toward exiting the Coverage Gap is $4,850.00. | |||||||
$ | 12: Dec | Catastrophic Coverage | $2.99 | $8.98 | $0.00 | $47.89 | $7,515.22 |
You exited the Coverage Gap (Donut Hole) in December 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 $3,031.11. | |||||||
Summary |
Who Pays | Total Retail |
|||||
You | Plan | Mfgr | Gov | ||||
Totals without premium: | $3,031.11 | $2,614.34 | $1,821.88 | $47.89 | $7,515.22 | ||
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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