Click here to see a comparison of plan parameters for all years since 2006
Medicare Part D Benefit Parameters for Defined Standard Benefit 2019 through 2023 Comparison |
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Part D Standard Benefit Design Parameters: | 2023 | 2022 | 2021 | 2020 | 2019 | |||||||||||||
Deductible - After the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. | $505 | $480 | $445 | $435 | $415 | |||||||||||||
Initial Coverage Limit - Coverage Gap (Donut Hole) begins when retail drug cost exceed this value. | $4,660 | $4,430 | $4,130 | $4,020 | $3,820 | |||||||||||||
Out-of-Pocket Threshold - This is the Total Out-of-Pocket (TrOOP) costs including the Donut Hole. | $7,400 | $7,050 | $6,550 | $6,350 | $5,100 | |||||||||||||
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap - (LIS) Catastrophic Coverage starts after this point. See note (1) below. | $10,516.25 (1) | $10,012.50 (1) | $9,313.75 (1) | $9,038.75 (1) | $7,653.75 (1) | |||||||||||||
CMS estimated average amount of total drug spending required to reach TrOOP (NON-LIS). See note (2). | $11,206.28 plus a 75% discount on all formulary drugs |
$10,690.20 plus a 75% discount on all formulary drugs |
$10,048.39 plus a 75% discount on all formulary drugs |
$9,719.38 plus a 75% discount on all formulary drugs |
$8,139.54 plus a 75% brand discount |
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Catastrophic Coverage Benefit: | ||||||||||||||||||
Generic/Preferred Multi-Source Drug (3) | $4.15 (3) | $3.95 (3) | $3.70 (3) | $3.60 (3) | $3.40 (3) | |||||||||||||
Other Drugs (3) | $10.35 (3) | $9.85 (3) | $9.20 (3) | $8.95 (3) | $8.50 (3) | |||||||||||||
Part D Full Benefit Dual Eligible (FBDE) Parameters: | 2023 | 2022 | 2021 | 2020 | 2019 | |||||||||||||
• 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 | $1.45 | $1.35 | $1.30 | $1.30 | $1.25 | |||||||||||||
- Other Drugs | $4.30 | $4.00 | $4.00 | $3.90 | $3.80 | |||||||||||||
• 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 | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | |||||||||||||
- Other Drugs | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | |||||||||||||
• 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: | 2023 | 2022 | 2021 | 2020 | 2019 | |||||||||||||
Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources ≤ $9,900 (individuals in 2022) or ≤ $15,600 (couples, 2022) (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 | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | |||||||||||||
- Other Drugs | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | |||||||||||||
• Maximum Copay above Out-of-Pocket Threshold | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||||||
Partial Subsidy Parameters: | 2023 | 2022 | 2021 | 2020 | 2019 | |||||||||||||
Applied and income below 150% FPL and resources between $15,510 (individual, 2022) or $30,950 (couples, 2022) (category code 4) (4) | ||||||||||||||||||
• Deductible | $104.00 | $99.00 | $92.00 | $89.00 | $85.00 | |||||||||||||
• Coinsurance up to Out-of-Pocket Threshold | 15% | 15% | 15% | 15% | 15% | |||||||||||||
• Maximum Copayments above Out-of-Pocket Threshold | ||||||||||||||||||
- Generic / Preferred Multi-Source Drug | $4.15 | $3.95 | $3.70 | $3.60 | $3.40 | |||||||||||||
- Other Drugs | $10.35 | $9.85 | $9.20 | $8.95 | $8.50 | |||||||||||||
(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. This is the estimated average amount of total drug spending required to reach the out-of-pocket threshold in the defined standard benefit. For 2023, the weighted gap coinsurance factor is 89.459%. This is based on the 2021 PDEs (92.13% Brands & 7.87% Generics). | ||||||||||||||||||
(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2023, beneficiaries will be charged $4.15 for those generic or preferred multisource drugs with a retail price under $83 and 5% for those with a retail price greater than $83. For brand-name drugs, beneficiaries would pay $10.35 for those drugs with a retail price under $207 and 5% for those with a retail price over $207. | ||||||||||||||||||
(4) This amount includes the $1,500 per person burial allowance. The resource limit may be updated during contract year 2023. |
Click here to see a comparison of plan parameters for all years since 2006
Click here to see a comparison of plan parameters for all years since 2006
2023 Full Low-Income Subsidy Income Requirements (135% of FPL) | |||
Persons in Family | 48 Contiguous States & D.C. | Alaska | Hawaii |
1 | $19,683 | $24,584 | $22,640 |
2 | $26,622 | $33,264 | $30,618 |
3 | $33,561 | $41,945 | $38,597 |
4 | $40,500 | $50,625 | $46,575 |
5 | $47,439 | $59,306 | $54,554 |
6 | $54,378 | $67,986 | $62,532 |