No. Your $4,700 total out-of-pocket spending limit (2015 TrOOP)
includes the portion of your $2,960 Initial Coverage Limit that you actually
paid for your medications - but, you cannot subtract the two numbers to
determine how much you will need to spend before leaving the Donut Hole.
You will stay in the 2015 Donut Hole until
your total out-of-pocket spending (not including monthly plan premiums) exceeds
the $4,700 out-of-pocket threshold (TrOOP)- less any brand-name drug discounts you receive while in
the Donut Hole (you can
click here to read more).
To keep things "simple" we use two different numbers to define your Medicare
Part D drug plan’s Donut Hole or Coverage Gap:
(1)
The Donut Hole entry point or The Initial Coverage Limit (ICL): The $2,960 is your 2015 Initial Coverage Limit or total
retail value of your drug purchases - so this $2,960 includes what you have
spent on medications
plus what your Medicare plan has contributed toward your
medications and determines when you enter the Donut Hole. When the total retail cost of your drug purchases exceeds $2,960, you go into the
2015 Donut Hole.
For
example, if you are in your Medicare Part D plan’s Initial Coverage Phase,
purchase a medication with a $100 retail cost, and only pay a $30 co-payment
out of your own pocket (the plan pays the other $70), you get $100 credit toward your $2,960 Initial Coverage
Limit.
(2)
The Donut Hole exit point or Total out-of-pocket (TrOOP) spending: After your
actual spending for covered medications has reached $4,700, you exit the 2015 Donut
Hole. Again, the brand-name discount
counts toward meeting this total out-of-pocket spending amount.
Using the same example: If you are in your Medicare Part D plan’s Initial Coverage Phase,
purchase a medication with a $100 retail cost, and only pay a $30 co-payment
out of your own pocket (the plan pays the other $70), you get $30 credit toward
the $4,700 Donut Hole exit point.
When you purchase a formulary medication
with a $100 retail cost and a $30 co-pay in 2015
|
|
Retail Cost
|
You Pay
|
Medicare Plan Pays
|
Pharma Mnfgr Pays
|
Gov. pays
|
Amount toward your TrOOP
|
Initial
Deductible *
|
$100
|
$100
|
$0
|
$0
|
$0
|
$100
|
Initial
Coverage Phase **
|
$100
|
$30
|
$70
|
$0
|
$0
|
$30
|
Coverage Gap -
brand-name ***
|
$100
|
$45
|
$5
|
$50
|
$0
|
$95
|
Coverage Gap -
generic ****
|
$100
|
$65
|
$35
|
$0
|
$0
|
$65
|
Catastrophic
Coverage (generic drug) *****
|
$100
|
$5
|
$15
|
$0
|
$80
|
$5
|
*
Retail Cost toward ICL
** $30 co-pay (
Retail Cost toward ICL)
*** 55% Brand-Name Donut Hole Discount
**** 35% Generic Donut Hole Discount
***** approx. 5% of retail or $6.60 for brand medications, whichever is higher (80% paid by Medicare, 15% paid by Medicare plan, and around 5% by plan member)
Now
when you are in the 2015 Donut Hole and you buy the same $100 medication, and your
plan does not have any Donut Hole coverage, you will get a 55% discount on
all brand-name drugs bought in the Donut Hole, or a 35% discount on generic
drugs purchased in the Donut Hole.
If
your $100 medication was a brand-name drug, then you will pay only $45 -
but, you will get credit for the $95 toward meeting your $4,700
out-of-pocket threshold or Donut Hole exit point. This $95 TrOOP credit represents the
$45 that you paid and the $50 that was paid on your behalf by the brand-name
drug manufacturer. You do not get credit
for the $5 that was paid by your Medicare Part D plan.
If
the $100 medication was a generic drug, you would pay $65 dollars and you would
get credit toward meeting the $4,700 Donut Hole exit point or out-of-pocket
threshold only for the actual $65 you spent.