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2018 Medicare Part D Outlook

Below are the preliminary 2018 Standard Benefit Model Plan parameters as released by The Centers for Medicare and Medicaid Services (CMS). The finalized parameters will be released in April 2017.



CMS Part D 2018 Standard Benefit Model Plan Feature Highlights

Here are the highlights for the CMS defined Standard Benefit Plan changes from 2017 to 2018. The chart below shows the Standard Benefit design changes for plan years 2014, 2015, 2016, 2017 and 2018. This "Standard Benefit Plan" is the minimum allowable plan to be offered.
  • Initial Deductible:
    will be increased by $5 to $405 in 2018.
  • Initial Coverage Limit:
    will increase from $3,700 in 2017 to $3,750 in 2018.
  • Out-of-Pocket Threshold:
    will increase from $4,950 in 2017 to $5,000 in 2018.
  • Coverage Gap (donut hole):
    begins once you reach your Medicare Part D plan’s initial coverage limit ($3,750 in 2018) and ends when you spend a total of $5,000 in 2018.
    In 2018, Part D enrollees will receive a 65% discount on the total cost of their brand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will apply to getting out of the donut hole, however the additional 15% paid by your Medicare Part D plan will not count toward your TrOOP.
    For example: if you reach the donut hole and purchase a brand-name medication with a retail cost of $100, you will pay $35 for the medication, and receive $85 credit toward meeting your 2018 total out-of-pocket spending limit.
    Enrollees will pay a maximum of 44% co-pay on generic drugs purchased while in the coverage gap (a 56% discount). For example: If you reach the 2018 Donut Hole, and your generic medication has a retail cost of $100, you will pay $44. The $44 that you spend will count toward your TrOOP.
  • Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**:
    will increase to greater of 5% or $3.35 for generic or preferred drug that is a multi-source drug and the greater of 5% or $8.35 for all other drugs in 2018.
  • Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees:
    will increase to $3.35 for generic or preferred drug that is a multi-source drug and $8.35 for all other drugs in 2018.




Chart Comparing 2014 through 2018 Standard Benefit Model Plan Features

Click here to see a comparison of plan parameters for all years 2006 to 2018

Medicare Part D Benefit Parameters for Defined Standard Benefit
2014 through 2018 Comparison
Part D Standard Benefit Design Parameters: 2018 2017 2016 2015 2014
Deductible - (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. $405 $400 $360 $320 $310
Initial Coverage Limit - Coverage Gap (Donut Hole) begins at this point. (The Beneficiary pays 100% of their prescription costs up to the Out-of-Pocket Threshold) $3,750 $3,700 $3,310 $2,960 $2,850
Out-of-Pocket Threshold - This is the Total Out-of-Pocket Costs including the Donut Hole. $5,000 $4,950 $4,850 $4,700 $4,550
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - Catastrophic Coverage starts after this point.

See note (1) below.
$7,508.75 (1) $7,425.00 (1) $7,062.50 (1) $6,680.00 (1) $6,455.00 (1)
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2). $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
Average NON-LIS percentage brand and generic drug purchases made during the coverage gap used to estimate the Total Covered Part D OOP threshold for NON-LIS beneficiaries (see above). Brand: 89.18%
Generic: 10.82%
Brand: 87.9%
Generic: 12.1%
Brand: 84.6%
Generic: 15.4%
Brand: 85.9%
Generic: 14.1%
Brand: 86.2%
Generic: 13.2%
Catastrophic Coverage Benefit:
   Generic/Preferred
   Multi-Source
     Drug
(3)
$3.35 (3) $3.30 (3) $2.95 (3) $2.65 (3) $2.55 (3)
    Other Drugs (3) $8.35 (3) $8.25 (3) $7.40 (3) $6.60 (3) $6.35 (3)
Part D Full Benefit Dual Eligible (FBDE) Parameters: 2018 2017 2016 2015 2014
   Deductible $0.00 $0.00 $0.00 $0.00 $0.00
   Copayments for
   Institutionalized
   Beneficiaries
$0.00 $0.00 $0.00 $0.00 $0.00
Maximum Copayments for Non-Institutionalized Beneficiaries
    Up to or at 100% FPL:
        Up to Out-of-Pocket Threshold
      Generic/Preferred
      Multi-Source
     Drug
$1.25 $1.20 $1.20 $1.20 $1.20
      Other $3.70 $3.70 $3.60 $3.60 $3.60
     Above Out-of-
     Pocket
     Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
    Over 100% FPL:
        Up to Out-of-Pocket Threshold
      Generic/Preferred
      Multi-Source
     Drug
$3.35 $3.30 $2.95 $2.65 $2.55
      Other $8.35 $8.25 $7.40 $6.60 $6.35
     Above Out-of-
     Pocket
     Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
Part D Full Subsidy - Non Full Benefit Dual Eligible Full Subsidy Parameters: 2018 2017 2016 2015 2014
Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources ≤ $8,890 (individuals) or ≤ $14,090 (couples) (4)
   Deductible $0.00 $0.00 $0.00 $0.00 $0.00
    Maximum Copayments up to Out-of-Pocket Threshold
      Generic/Preferred
      Multi-Source
     Drug
$3.35 $3.30 $2.95 $2.65 $2.55
      Other $8.35 $8.25 $7.40 $6.60 $6.35
   Maximum Copay
     above
   Out-of-Pocket
   Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
Partial Subsidy Parameters: 2018 2017 2016 2015 2014
Applied and income below 150% FPL and resources between $8,890-$13,820 (individuals) or $143,090-$27,600 (couples) (category code 4) (4)
   Deductible $83.00 $82.00 $74.00 $66.00 $63.00
   Coinsurance
     up to
   Out-of-Pocket
   Threshold
15% 15% 15% 15% 15%
    Maximum Copayments above Out-of-Pocket Threshold
      Generic/Preferred
      Multi-Source
     Drug
$3.35 $3.30 $2.95 $2.65 $2.55
      Other $8.35 $8.25 $7.40 $6.60 $6.35
(1) Total Covered Part D Spending at Out-of-Pocket Threshold for Non-Applicable Beneficiaries - Beneficiaries who ARE entitled to an income-related subsidy under section 1860D-14(a) (LIS)
(2) Total Covered Part D Spending at Out-of-Pocket Threshold for Applicable Beneficiaries - Beneficiaries who are NOT entitled to an income-related subsidy under section 1860D-14(a) (NON-LIS) and do receive the coverage gap discount. For 2018, the weighted gap coinsurance factor is 80.5286%. This is based on the 2016 PDEs (89.18% Brands & 10.82% Generics)
(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2018, beneficiaries will be charged $3.35 for those generic or preferred multisource drugs with a retail price under $67 and 5% for those with a retail price greater than $67. For brand-name drugs, beneficiaries would pay $8.35 for those drugs with a retail price under $167 and 5% for those with a retail price over $167.
(4) The actual amount of resources allowable may be updated for contract year 2017.




2016 Federal Poverty Level Guidelines: LIS Qualifications (2016-2017)

If your income is below 135% of the FPL, you could qualify for the full Low-Income Subsidy (resource limits also apply - see chart above). Even if you don’t qualify for full LIS benefits, you could be eligible for partial LIS benefits if your income level is at or below 150% FPL (resource limits also apply - see chart above). Remember, the LIS subsidy helps to pay both your monthly plan premiums and drug costs.

The 2017-2018 FPL has not yet been released. You can learn more about the 2016-2017 FPL in our article, 2016 Federal Poverty Level Guidelines: 2016-2017 LIS Qualifications.



Full Low-Income Subsidy Income Requirements (100% of FPL)
Persons
in Family
48 Contiguous
States & D.C.
AlaskaHawaii
1 $11,880 $14,840 $13,670
2 $16,020 $20,020 $18,430
3 $20,160 $25,200 $23,190
4 $24,300 $30,380 $27,950
5 $28,440 $35,560 $32,710
6 $32,580 $40,740 $37,470
Click here for additional family member figures

Learn more about the Extra-Help program.




Sign-up for our 2018 Reminder Service



2018 Medicare Part D Plan Reminder Service

If you would like for us to send you an email as the 2018 Medicare Part D plan information becomes available, as it is updated and when enrollment begins (October 15th), please complete the form below. We will NOT share your information with any third-parties.

Please provide the following Information
First Name (optional)
Last Name (optional)
eMail*   
State*   
I’m interested in:* Medicare Advantage (Health) Plans  
      with Prescription Drug Coverage       
Prescription Drug Only Plans
Both Medicare Advantage Plans
      and Drug Only Plans
I would like to receive the free Medicare Part D Newsletter
      (Your personal information is never shared.)
   *Required


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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.