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2019-2006 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 2019 through 2006.


Medicare Part D Benefit Parameters for Defined Standard Benefit
2006 through 2019 Comparison
Part D Standard Benefit Design Parameters: 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. $415 $405 $400 $360 $320 $310 $325 $320 $310 $310 $295 $275 $265 $250
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) $3,820 $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 Costs including the Donut Hole. $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 - Catastrophic Coverage starts after this point.

See note (1) below.		 $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
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2). $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) $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) $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: 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
• 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
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 $1.25 $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 $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
Over 100% FPL:
• Up to Out-of-Pocket Threshold
- Generic / Preferred Multi-Source Drug $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 $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
Part D Full Subsidy - Non Full Benefit Dual Eligible Full Subsidy Parameters: 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 ≤ $9,060 (individuals in 2018) or ≤ $14,340 (couples, 2018) (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
• Maximum Copayments up to Out-of-Pocket Threshold
- Generic / Preferred Multi-Source Drug $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 $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
Partial Subsidy Parameters: 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006
Applied and income below 150% FPL and resources between $14,100 (individual, 2018) or $28,150 (couples, 2018) (category code 4) (4)
• Deductible $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%
• Maximum Copayments above Out-of-Pocket Threshold
- Generic / Preferred Multi-Source Drug $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 $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. For 2019, the weighted gap coinsurance factor is 75.3704%. This is based on the 2017 PDEs (89.81% Brands & 10.69% Generics)
(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2019, beneficiaries will be charged $3.40 for those generic or preferred multisource drugs with a retail price under $68 and 5% for those with a retail price greater than $68. For brand-name drugs, beneficiaries would pay $8.50 for those drugs with a retail price under $170 and 5% for those with a retail price over $170.
(4) This amount includes the $1,500 per person burial allowance. The resource limit may be updated during contract year 2018.






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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.
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  • 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.
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