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2023-2006 Medicare Part D Standard Benefit Model Plan Parameters

 Below is a comparison of the Standard Benefit Model Plan parameters as released by The Centers for Medicare and Medicaid Services (CMS) for the plan years 2023 through 2006.


Medicare Part D Benefit Parameters for Defined Standard Benefit
2006 through 2023 Comparison
Part D Standard Benefit Design Parameters: 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006
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 $405 $400 $360 $320 $310 $325 $320 $310 $310 $295 $275 $265 $250
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 $3,750 $3,700 $3,310 $2,960 $2,850 $2,970 $2,930 $2,840 $2,830 $2,700 $2,510 $2,400 $2,250
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 $5,000 $4,950 $4,850 $4,700 $4,550 $4,750 $4,700 $4,550 $4,550 $4,350 $4,050 $3,850 $3,600
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) $7,508.75 (1) $7,425.00 (1) $7,062.50 (1) $6,680.00 (1) $6,455.00 (1) $6,733.75 (1) $6,657.50 (1) $6,447.50 (1) $6,440.00


plus a
$250 rebate

 $6,153.75 $5,726.25 $5,451.25 $5,100.00
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		 $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		 $6,954.52

plus a 52.50% brand discount		 $6,730.39

plus a 50% brand discount		 $6,483.72

plus a 50% brand discount		          
Catastrophic Coverage Benefit:
Generic/Preferred Multi-Source Drug (3) $4.15 (3) $3.95 (3) $3.70 (3) $3.60 (3) $3.40 (3) $3.35 (3) $3.30 (3) $2.95 (3) $2.65 (3) $2.55 (3) $2.65 (3) $2.60 (3) $2.50 (3) $2.50 (3) $2.40 (3) $2.25 (3) $2.15 (3) $2.00 (3)
Other Drugs (3) $10.35 (3) $9.85 (3) $9.20 (3) $8.95 (3) $8.50 (3) $8.35 (3) $8.25 (3) $7.40 (3) $6.60 (3) $6.35 (3) $6.60 (3) $6.50 (3) $6.30 (3) $6.30 (3) $6.00 (3) $5.60 (3) $5.35 (3) $5.00 (3)
Part D Full Benefit Dual Eligible (FBDE) Parameters: 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006
• Deductible $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
• Copayments for Institutionalized Beneficiaries $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $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 $1.25 $1.20 $1.20 $1.20 $1.20 $1.15 $1.10 $1.10 $1.10 $1.10 $1.05 $1.00 $1.00
- Other Drugs $4.30 $4.00 $4.00 $3.90 $3.80 $3.70 $3.70 $3.60 $3.60 $3.60 $3.50 $3.30 $3.30 $3.30 $3.20 $3.10 $3.10 $3.00
• Above Out-of-Pocket Threshold $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $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 $3.35 $3.30 $2.95 $2.65 $2.55 $2.65 $2.60 $2.50 $2.50 $2.40 $2.25 $2.15 $2.00
- Other Drugs $10.35 $9.85 $9.20 $8.95 $8.50 $8.35 $8.25 $7.40 $6.60 $6.35 $6.60 $6.50 $6.30 $6.30 $6.00 $5.60 $5.35 $5.00
• Above Out-of-Pocket Threshold $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $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 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006
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 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $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 $3.35 $3.30 $2.95 $2.65 $2.55 $2.65 $2.60 $2.50 $2.50 $2.40 $2.25 $2.15 $2.00
- Other Drugs $10.35 $9.85 $9.20 $8.95 $8.50 $8.35 $8.25 $7.40 $6.60 $6.35 $6.60 $6.50 $6.30 $6.30 $6.00 $5.60 $5.35 $5.00
• Maximum Copay above Out-of-Pocket Threshold $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Partial Subsidy Parameters: 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006
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 $83.00 $82.00 $74.00 $66.00 $63.00 $66.00 $65.00 $63.00 $63.00 $60.00 $56.00 $53.00 $50.00
• Coinsurance up to Out-of-Pocket Threshold 15% 15% 15% 15% 15% 15% 15% 15% 15% 15% 15% 15% 15% 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 $3.35 $3.30 $2.95 $2.65 $2.55 $2.65 $2.60 $2.50 $2.50 $2.40 $2.25 $2.15 $2.00
- Other Drugs $10.35 $9.85 $9.20 $8.95 $8.50 $8.35 $8.25 $7.40 $6.60 $6.35 $6.60 $6.50 $6.30 $6.30 $6.00 $5.60 $5.35 $5.00
(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.






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