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Fewer Medicare Advantage plans will offer a variation on the standard Initial Coverage Limit in 2021

Category: Annual Medicare Plan Changes
Published on 2020-10-03 13:37:08


Although, the vast majority of Medicare Advantage plans with drug coverage (MAPDs) will use the standard defined 2021 Medicare Part D Initial Coverage Limit (ICL) of $4,130, a few 2021 MAPDs will have an ICL that is higher or lower than the standard.  And one stand-alone Medicare Part D plan in New York will have a lower ICL.

Question:  Why is the ICL important?

Medicare prescription drug plans use the Initial Coverage Limit (ICL) to define when Medicare beneficiaries enter the Donut Hole or Coverage Gap.  If a Medicare Advantage plan (MAPD) follows the standard defined Medicare Part D plan parameters, plan members will enter the 2021 Donut Hole when their total negotiated retail prescription drug costs reach $4,130, a $110 increase over the 2020 standard Initial Coverage Limit of $4,020.

This means, if your Medicare Part D plan or Medicare Advantage plan follows the standard defined ICL and you purchase medications with an average retail value of less than $344 per month, you will NOT enter the 2021 Donut Hole.


Phases of your Medicare Part D coverage

Question:  What does it mean when my plan has a higher ICL?

If your Medicare drug plan has an ICL higher than the standard ICL, you will be able to buy more medications before reaching the 2021 Donut Hole or Coverage Gap.

Question:  What does it mean when my plan has a lower ICL?

If your Medicare Advantage plan has an ICL under $4,130, you will be able to buy fewer medications before reaching the 2021 Donut Hole or Coverage Gap.

Remember, in the Initial Coverage phase, when you purchase a drug with a $100 retail cost, the entire $100 retail cost counts toward reaching your ICL.  Whereas, only the amount you pay counts toward TrOOP or getting out of the Donut Hole. The portion paid by your Medicare Part D plan does not count toward getting out of the Donut Hole.

2021 Medicare Advantage plan ICL Landscape:

As compared to 2020, slightly more 2021 Medicare Advantage plans will offer an ICL above the standard $4,130 ICL and fewer 2021 Medicare Advantage plans will offer an ICL below the 2021 standard ICL of $4,130 (see the chart below for more details).

In fact, 25 Medicare Advantage plans (MAPDs) will have an ICL above the standard ICL of $4,130 in 2021 (all located in Florida) — with the highest ICL at $10,000 (this means plan members can buy formulary drugs with a retail value up to $10,000 before reaching the Coverage Gap).  In 2020, 22 Medicare Advantage plans offered an ICL that was higher than the standard ICL of $4,020. 

Only nine MAPDs will have an ICL below the standard ICL in 2021 as compared to 13 plans with a lower ICL in 2020. The 44 Medicare Advantage plans with a $0 Initial Coverage Limit are Medicare-Medicaid Plans.


2021 Medicare Advantage Plans
Initial Coverage Limits
ICL Nbr of
2021 Plans
Nbr of
2020 Plans
Nbr of
2019 Plans
$0444450
$2,750 1 
$3,130  1
$3,500  2
$3,570 1 
$3,595 11
$3,605  2
$3,635  1
$3,655  3
$3,665 1 
$3,700  1
$3,750 1 
$3,785 2 
$3,820  3,047***
$3,835 1 
$3,880 4 
$3,8852  
$3,9351  
$3,98051 
$4,000  6
$4,020 3,656** 
$4,0801  
$4,1304,108*  
$4,50054 
$5,00044 
$6,000752
$6,350
1 
$7,000342
$7,5001  
$8,000233
$9,5002  
$10,00011 

Notes:  The Medicare Advantage plans with a $0 Initial Coverage Limit are Medicare-Medicaid Plans.
              *$4,130 is the 2021 standard Initial Coverage Limit
            **$4,020 is the 2020 standard Initial Coverage Limit
          ***$3,820 is the 2019 standard Initial Coverage Limit



Here is some positive news...

The Medicare Advantage plans with Initial Coverage Limits over the 2021 standard ICL of $4,130 are available in three counties in Florida.

2021 Medicare Advantage Plans
with Increased Initial Coverage Limit (ICL)
Location ICL Nbr of Plans
Miami-Dade $4,500 3
Broward $4,500 3
Palm Beach $4,500 1
Miami-Dade $5,000 4
Miami-Dade $6,000 6
Broward $6,000 1
Miami-Dade $7,000 3
Broward $7,500 1
Miami-Dade $7,500 1
Palm Beach $7,500 1
Miami-Dade $8,000 2
Miami-Dade $9,500 2
Miami-Dade $10,000 1

The 2021 Medicare Advantage plan information available in our 2021 Medicare Advantage plan finder (or MA-Finder) can also be found directly at: MA-Finder.com/2021.

See how each 2020 Medicare Advantage plan is changing in 2021 using our MA-Compare.com/2021.
For an example, here is a link to Summit County, OH.

Question:  Will any 2021 stand-alone Medicare Part D plans have an ICL that is different from the standard?

Yes.  One stand-alone 2021 Medicare Part D prescription drug plan (PDP) will have an Initial Coverage Limit that is lower than the standard $4,130 ICL.  The 2021 New York EmblemHealth VIP Rx Plus (PDP) will have an ICL of $3,970 - meaning that with this PDP, you will enter the Donut Hole slightly faster than a Medicare Part D plan with the higher $4,130 ICL.






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