No. Your $4,700 total out-of-pocket spending limit (
2017 TrOOP)
includes only the portion of your
$3,700 Initial Coverage Limit that you
actually
paid for your medications - so, you cannot just subtract the two numbers to
determine how much you will need to spend before leaving the Donut Hole.
As an example, if you purchase a medication with a retail
cost of $100 and you pay a $30 co-payment for the drug (your Medicare Part D plan pays the $70 balance toward the
$100 prescription), the total retail value of
$100 counts toward meeting your Initial Coverage Limit and moves you
$100 closer to entering the Donut Hole or Coverage Gap - but only the amount you spent ($30) counts toward exiting your Donut Hole or meeting your 2017 TrOOP limit of $4,950.
So you will stay in the 2017 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 about the amount of a Donut Hole purchase that counts toward getting out of the Donut Hole).
And in more detail - the long answer:
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): As noted, $3,700 is your 2017 Initial Coverage Limit or total
retail value of your drug purchases before entering the Donut Hole. So this $3,700 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. Again, when the total retail cost of your drug purchases exceeds $3,700, you go into the
2017 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 pay 25% co-insurance for the drug (the plan pays the other $75), you get the $100 retail drug cost credited toward your $3,700 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 $4,950, you exit the 2017 Donut
Hole. As noted above, 50% of 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 25% co-insurance (the plan pays the other $75), you get $25 credit toward
the $4,950 Donut Hole exit point.
How the Donut Hole discount affects TrOOP
When you are in the 2017 Donut Hole and you buy the same $100 medication, and your
plan does not have any additional Donut Hole coverage, you will get a 60% discount on
all brand-name drugs bought in the Donut Hole, or a 49% discount on generic
drugs purchased in the Donut Hole.
If
your $100 medication was a brand-name drug, then you will pay only $40 -
but, you will get credit for the $90 toward meeting your $4,950
out-of-pocket threshold or Donut Hole exit point. This $90 TrOOP credit represents the
$40 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 $10 that was paid by your Medicare Part D plan.
If
the $100 medication was a generic drug, you would pay $51 dollars and you would
get credit toward meeting the $4,950 Donut Hole exit point or out-of-pocket
threshold only for the actual $51 you spent.
When you purchase a formulary medication
with a $100 retail cost and a $30 co-pay in 2017
|
|
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
|
$40
|
$10
|
$50
|
$0
|
$90
|
Coverage Gap -
(generic) ****
|
$100
|
$51
|
$49
|
$0
|
$0
|
$51
|
Catastrophic
Coverage (generic) *****
|
$100
|
$5
|
$15
|
$0
|
$80
|
$5
|
*
Retail Cost toward ICL
** assume a $30 co-pay (
Retail Cost toward ICL)
*** 60% Brand-Name Donut Hole Discount
**** 49% Generic Donut Hole Discount
***** approx. 5% of retail or $8.25 for brand medications (or $3.30 for generics), whichever is higher
See also:
"An explanation of the 2017 Medicare Part D Coverage Gap or Donut Hole."
https://Q1News.com/575.html
"Is the Medicare Part D Donut Hole any different if I am enrolled in a Medicare Advantage plan with drug coverage?"
https://Q1News.com/463.html