2019 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: | |
10.69% Generic / 89.31% 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: | $2,401.07 |
2019 Donut Hole Calculation Details | |||||||
Month |
Plan Phase |
Who Pays | Total Retail |
||||
You | Plan | Mfgr | Gov | ||||
$$$ | 1: Jan | Deductible | $415.00 | $0.00 | $0.00 | $0.00 | $415.00 |
Your deductible is less than your Rx costs for the month, so here we will use the deductible of $415 and on the next line you will see your initial coverage costs for the remainder of this month. Your costs so far $415. | |||||||
$$ | 1: Jan | Initial Coverage | $65.82 | $197.47 | $0.00 | $0.00 | $678.30 |
You satisfied the remainder of your deductible ($415) earlier this month. Now, in the Initial Coverage phase, you pay 25% of the remaining Rx costs for the month ($263.30) (upto the initial coverage limit--ICL) and your plan pays 75%. Some plan offer copayments instead.* Your costs so far $480.82. | |||||||
$$ | 2: Feb | Initial Coverage | $169.57 | $508.72 | $0.00 | $0.00 | $1,356.59 |
You are in the Initial Coverage Phase. Your costs so far $650.40. | |||||||
$$ | 3: Mar | Initial Coverage | $169.57 | $508.72 | $0.00 | $0.00 | $2,034.89 |
You are in the Initial Coverage Phase. Your costs so far $819.97. | |||||||
$$ | 4: Apr | Initial Coverage | $169.57 | $508.72 | $0.00 | $0.00 | $2,713.18 |
You are in the Initial Coverage Phase. Your costs so far $989.55. | |||||||
$$ | 5: May | Initial Coverage | $169.57 | $508.72 | $0.00 | $0.00 | $3,391.48 |
You are in the Initial Coverage Phase. Your costs so far $1,159.12. | |||||||
$$ | 6: Jun | Initial Coverage | $107.13 | $321.39 | $0.00 | $0.00 | $3,820.00 |
You are in the Initial Coverage Phase. Your costs so far $1,266.25. | |||||||
$$ | 6: Jun | Donut Hole | $65.65 | $27.97 | $156.15 | $0.00 | $4,069.77 |
You entered the Coverage Gap (Donut Hole) in June. Your costs so far including the 2019 Coverage Gap Discount are $1,331.90. Your credit toward exiting the Coverage Gap is $1,488.05. This includes what you spent plus what the brand-name drug manufacturer (Mfgr) spent on your behalf. For plan year 2019, Non-LIS Medicare Beneficiaries get a 63% discount on generics and a 75% discount on brand-name drugs purchased in the Coverage Gap. Read Q&A about the Discount... | |||||||
$$ | 7: Jul | Donut Hole | $178.27 | $75.97 | $424.05 | $0.00 | $4,748.07 |
You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,510.17. Your credit toward exiting the Coverage Gap is $2,090.37. | |||||||
$$ | 8: Aug | Donut Hole | $178.27 | $75.97 | $424.05 | $0.00 | $5,426.36 |
You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,688.45. Your credit toward exiting the Coverage Gap is $2,692.69. | |||||||
$$ | 9: Sep | Donut Hole | $178.27 | $75.97 | $424.05 | $0.00 | $6,104.66 |
You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,866.72. Your credit toward exiting the Coverage Gap is $3,295.02. | |||||||
$$ | 10: Oct | Donut Hole | $178.27 | $75.97 | $424.05 | $0.00 | $6,782.95 |
You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $2,045.00. Your credit toward exiting the Coverage Gap is $3,897.34. | |||||||
$$ | 11: Nov | Donut Hole | $178.27 | $75.97 | $424.05 | $0.00 | $7,461.25 |
You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $2,223.27. Your credit toward exiting the Coverage Gap is $4,499.67. | |||||||
$$ | 12: Dec | Donut Hole | $177.69 | $75.72 | $422.65 | $0.00 | $8,137.30 |
You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $2,400.96. Your credit toward exiting the Coverage Gap is $5,100.00. | |||||||
$ | 12: Dec | Catastrophic Coverage | $0.11 | $0.34 | $0.00 | $1.80 | $8,139.54 |
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 $3.40 for generics, $8.5 for brands or 5% whichever is higher. Your costs so far $2,401.07. | |||||||
Summary |
Who Pays | Total Retail |
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You | Plan | Mfgr | Gov | ||||
Totals without premium: | $2,401.07 | $3,037.63 | $2,699.04 | $1.80 | $8,139.54 | ||
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 2019, your drug costs are also shared during the Coverage Gap. The plan pays 63% of your generic drug costs and the drug manufacturer pays 75% 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 $3.40 for generics or $8.5 for brand drugs (whichever is higher). |
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