Here is a “basic” Medicare Part D question that came in from our Medicare Part D community.
If a Medicare Part D beneficiary purchases a very expensive Tier 4 specialty medication, for instance Revlimid®, which retails for about $7,444, they should, in theory, go through the Doughnut Hole or Coverage Gap in record time. More specifically, they should go though their initial deductible (if any) – their initial coverage phase - the Doughnut Hole portion of their Part D coverage (assuming they do not have complete Doughnut Hole coverage) - and finally into Catastrophic Coverage in their first month – or their first purchase.
The question for this article is whether the costs for a single prescription purchase will be split over all of the different Medicare Part D phases?
Our on this site Doughnut Hole Calculator helps people get an estimate of Doughnut Hole timing and we have our calculator programmed to assume that the price of one prescription will be allotted or split over the different Part D plan phases. So with our calculator, the Medicare Part D beneficiary would pay:
(1) Assume no initial deductible
(2) Initial coverage up to the Doughnut Hole of $600 +
(3) Doughnut Hole costs of $3,051.25 +
(4) Catastrophic coverage costs of $99.66 in the first month
However, the online prescription drug plan selection tool provided by the Centers for Medicare and Medicaid Services (CMS) shows a different result. The CMS online system shows that the Medicare Part D beneficiary pays:
(1) $7,444.48 of there is an initial deductible phase +
(2) co-payment charges of $2,456.68 (or co-insurance charges of $1,861.12) during the initial coverage phase +
(3) $7,444.48 again when in the Doughnut Hole +
(4) $372.22 during the Catastrophic coverage phase
The total monthly drug costs are listed as $7,444.48.
Although the final annual drug plan costs appear to be correct. The CMS system seems to show the cost of the single medication purchase is not spread over the different Part D plan coverage phases, but is instead kept somewhat intact through each phase.
Again, the question from members of our online community is simply whether the costs of a single prescription purchase
will be split over several Part D phases and stay strictly within the parameters of the Medicare Part D true our of pocket cost limits?
And the answer is... Yes, the cost is split over the various phases of coverage as the limits of each phase are met and surpassed.