A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search

2017 CMS Advance Notice: A preview into next year's Medicare Part D standard prescription drug plan coverage

Category: Annual Medicare plan changes
Published: Feb, 19 2016 08:02:37


The Centers for Medicare and Medicaid Services (CMS) has released their 2017 Advance Notice and Draft Call Letter that includes a preview of the defined standard benefits for 2017 Medicare Part D prescription drug plan coverage.  These parameters will be finalized or updated in April when CMS releases their final "Announcement of Calendar Year 2017 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies".

As reference, a chart comparing the standard benefit parameters from 2013 through 2017 is available at: Q1Medicare.com/2017.  (And for a little history, the following link leads to a chart of the standard Medicare Part D benefit parameters from 2006 through 2017: Q1Medicare.com/PartD-The-MedicarePartDOutlookAllYears.php.)

From the CMS Advance Notice, here is a preview of what you can expect for standard 2017 Medicare Part D prescription drug coverage:
  • The standard Initial Deductible will increase.  The 2017 standard Initial Deductible will increase $40 to $400. The current 2016 standard Initial Deductible is $360 and the 2015 Initial Deductible was $320.

    This means: If you enroll in a Medicare Part D prescription drug plan with a standard initial deductible, you will pay slightly more in 2017 before your drug plan coverage begins.

  • The Initial Coverage Limit will increase.  The 2017 Initial Coverage Limit will increase to $3,700. If finalized, Medicare beneficiaries will enter the 2017 Donut Hole or Coverage Gap when the total negotiated retail value of their prescription drug purchases reaches the Initial Coverage limit of $3,700, a $390 increase over the 2016 Initial Coverage Limit of $3,310. The 2015 Initial Coverage Limit was $2,960.

    This means: You will be able to buy slightly more medications before reaching the 2017 Donut Hole or Coverage Gap. Please note, if you purchase medications with an average retail value of less than $309 per month, you will not enter the 2017 Donut Hole.

  • The Donut Hole discount will increase for generic drugs.  Next year, if you reach the Donut Hole or Coverage Gap phase of your Medicare Part D plan coverage, the 2017 generic drug discount will increase from 42% to 49%.

    This means: If you reach the 2017 Donut Hole, and your generic medication has a retail cost of $100, you will pay $51 and the $51 that you spend will count toward your 2017 out-of-pocket spending limit or TrOOP of $4,950.

  • The Donut Hole discount will increase for brand-name drugs.  The 2017 brand-name drug discount will increase to 60% (from the 2016 discount of 55%) and you will receive credit for 90% of the retail drug cost toward meeting your 2017 total out-of-pocket maximum or Donut Hole exit point (the 40% you spend plus the 50% drug manufacturer discount).

    This means: If you reach the 2017 Donut Hole and purchase a brand-name medication with a retail cost of $100, you will pay $40 for the medication (60% discount), and receive $90 credit toward meeting your 2017 out-of-pocket spending limit – or Donut Hole exit point of $4,950.

  • Total Out-of-Pocket Costs or TrOOP will increase.  TrOOP is the dollar figure you must spend to get out of the Donut Hole or Coverage Gap, excluding monthly premiums. The 2017 TrOOP threshold will increase by $100 to $4,950 from the current 2016 value of $4,850. The 2015 TrOOP threshold value was $4,700. As noted above, brand-name medication purchases in the Donut Hole are discounted by 60%, but you will receive credit of 90% of the retail drug price toward meeting the 2017 TrOOP threshold.

    This means:
    You will have to spend slightly more to get out of the 2017 Donut Hole than you did in 2016.  If you purchase only generic medications while in the Donut Hole, you would be able purchase medications worth a retail cost of $7,425 before reaching your TrOOP or exiting the Donut Hole and entering Catastrophic Coverage.  Based on past drug purchases, CMS estimates that most people will use a mix of 12.1% generics and 87.9% brand name drugs during the Donut Hole, and based on these estimates, you would have to purchase $8,071.16 worth of prescriptions before existing the 2017 Donut Hole.  So, on average, if a person purchases medications with a total retail cost of over $673 per month, they will exit the Donut Hole and enter the Catastrophic Coverage phase of their Medicare Part D plan.

  • The minimum cost-sharing in the Catastrophic Coverage phase will increase slightly.  Once someone has exceeded their TrOOP, they will enter the 2017 Catastrophic Coverage phase and pay $3.30 (up from $2.95) for generics (or a preferred drug that is a multi-source drug) and $8.25 (up from $7.40) for all other drugs - or 5% of the retail drug cost, whichever is higher.

  • No 2017 Medicare Advantage plan can have an in-network Maximum Out-of-Pocket (MOOP) spending limit over $6,700.  CMS sets a limit on how high a Medicare Advantage plan can set their Medicare Part A and Medicare Part B Maximum Out-of-Pocket limit (MOOP) and, as in 2016 and 2015, no Medicare Advantage plan can have a MOOP higher than $6,700 for in-network eligible medical cost-sharing.

    The 2017 CMS Advance Notice notes: "The mandatory MOOP amount represented approximately the 95th percentile of projected beneficiary out-of-pocket spending. Stated differently, five percent of Original Medicare beneficiaries are expected to incur approximately $6,700 or more in Parts A and B deductibles, copayments and coinsurance. The voluntary MOOP amount of $3,400 represents approximately the 85th percentile of projected Original Medicare out-of-pocket costs."

    This means:
    Although your Medicare Advantage plan can raise your maximum out-of-pocket spending limit (MOOP) in 2017, you can expect that your Medicare Advantage plan covered healthcare expenses will not exceed $6,700 for in-network cost-sharing.  (Key Point:  Be prepared to read your October 2016 Annual Notice of Change Letter to see if your MOOP increased - this may help you determine how much you need to budget in 2017 for in-network Medicare Part A and Medicare Part B coverage.)

    Source as of 02/19/2016: (https://www.cms.gov/ Medicare/ Health-Plans/ MedicareAdvtgSpecRateStats/ Downloads/ Advance2017.pdf)

In the February 19, 2016 Press Release announcing the 2017 Advance Notice and Draft Call Letter, CMS also adds:

"Enrollment and quality have grown in Medicare Advantage and Part D since enactment of the Affordable Care Act:
  • Medicare Advantage has reached record high enrollment each year since 2010, a trend continuing in 2016 with a cumulative increase of 50 percent to an all-time high of more than 17.1 million beneficiaries.

  • Nearly 32 percent of Medicare beneficiaries are enrolled in a Medicare Advantage plan.

  • Average Medicare Advantage premiums have fallen by nearly 10 percent from 2010 to 2016.

  • The percentage of Medicare Advantage enrollees in four or five star contracts has almost quadrupled since 2009 to 71 percent.

  • About one-third of prescription drug plan enrollees are in Part D plans with four or more stars, compared to 27 percent of enrollees in such plans in 2009.
The average number of Medicare plan choices remains consistent in 2016 as compared to 2015, and access to supplemental benefits, such as dental and vision benefits, is growing. The proposed policies in the Advance Notice and Draft Call Letter continue to strengthen and improve the Medicare Advantage program for current and future generations, including the program’s ability to serve Medicare beneficiaries with diverse needs."

(source: https://www.cms.gov/ Newsroom/ MediaReleaseDatabase/ Press-releases/ 2016-Press-releases-items/ 2016-02-19.html) [highlighting added]

For more information on the statistics related to 2016 Medicare Part D plans, please see our 2016 PDP Facts at PDP-Facts.com.









Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs




Ask a Pharmacist*
Have questions about your medication?

» Answers to Your Medication Questions, Free!
Available Monday - Friday
8am to 5pm MST
*A free service included with your no cost drug discount card.




Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.