2015 Medicare Part D [What it is = How it works]?

Posted on February 13, 2015 by Dr. David Edward Marcinko MBA MEd CMP™

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Update on the Medicare prescription drug benefit program

[By Staff Reporters]

Part D

Medicare Part D, also called the Medicare prescription drug benefit, is a United States federal-government program to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries. It was enacted as part of the Medicare Modernization Act of 2003 (which also made changes to the public Part C Medicare health plan program) and went into effect on January 1, 2006.

Medicare Part D Premiums

The monthly Medicare Part D base premium is set to pay 25.5 percent of the cost of standard coverage, established by bids submitted annually by Part D plans. CMS releases the Medicare Part D base premium in early August each year. Actual premiums are based on this set premium, but can vary greatly. The premium for 2014 was $32.42.

As of 2011, beneficiaries with higher incomes must pay a premium adjustment based on their income. This premium adjustment is called the Income-Related Monthly Adjustment Amount (IRMAA), and is paid directly to the Federal government (deducted from Social Security, Railroad Retirement Board, or Office of Personnel Management benefits).

Medicare Part D Deductible

The annual deductible for the standard Medicare Part D benefit was $310 in 2014, which is a decrease of $10 from the 2013 deductible. No Medicare drug plan may have a deductible more than $310 in 2014, although some plans may have a lower deductible or no deductible at all.

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CMS Part D 2015 Standard Benefit Model Plan Details

Here are the highlights for the CMS defined Standard Benefit Plan changes from 2014 to 2015. The chart below shows the Standard Benefit design changes for plan years 2011, 2012, 2013, 2014 and 2015. This “Standard Benefit Plan” is the minimum allowable plan to be offered.

  • Initial Deductible: will be increased by $10 to $320 in 2015
  • Initial Coverage Limit: will increase from $2,850 in 2014 to $2,960 in 2015
  • Out-of-Pocket Threshold: will increase from $4,550 in 2014 to $4,700 in 2015
  • Coverage Gap (donut hole): begins once you reach your Medicare Part D plan’s initial coverage limit ($2,960 in 2015) and ends when you spend a total of $4,700 in 2015. In 2015, Part D enrollees will receive a 55% discount on the total cost of their brand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will still apply to getting out of the donut hole, however the additional 5% paid by your Medicare Part D plan will not count toward your TrOOP. Enrollees will pay a maximum of 65% co-pay on generic drugs purchased while in the coverage gap.
  • Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**: will increase to greater of 5% or $2.65 for generic or preferred drug that is a multi-source drug and the greater of 5% or $6.60 for all other drugs in 2015
  • Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $2.65 for generic or preferred drug that is a multi-source drug and $6.60 for all other drugs in 2015.

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Medicare Part D Benefit Parameters for Defined Standard Benefit 2011 through 2015 Comparison
Part D Standard Benefit Design Parameters: 2015 2014 2013 2012 2011
Deductible – (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. $320 $310 $325 $320 $310
Initial Coverage Limit – Coverage Gap (Donut Hole) begins at this point. (The Beneficiary pays 100% of their prescription costs up to the Out-of-Pocket Threshold) $2,960 $2,850 $2,970 $2,930 $2,840
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap – Catastrophic Coverage starts after this point. See note (1) below. $6,680.00 (1) $6,455.00 (1) $6,733.75 (1) $6,657.50 (1) $6,447.50 (1)
Out-of-Pocket Threshold – This is the Total Out-of-Pocket Costs including the Donut Hole. 2015 Example:    $320 (Deductible) +(($2960-$320)*25%) (Initial Coverage) +(($6680.00-$2960)*100%) (Cov. Gap) = $4,700 (Maximum Out-Of-Pocket Cost prior to Catastrophic Coverage – excluding plan premium) $4,700 $320.00 $660.00 $3,720.00 $4,700.00 $4,550 $310.00 $635.00 $3,605.00 $4,550.00 $4,750 $325.00 $661.25 $3,763.75 $4,750.00 $4,700 $320.00 $652.50 $3,727.50 $4,700.00 $4,550 $310.00 $632.50 $3,607.50 $4,550.00
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS) See note (2). $7,061.76 plus a 55% brand discount $6,690.77 plus a 52.50% brand discount $6,954.52 plus a 52.50% brand discount $6,730.39 plus a 50% brand discount $6,483.72 plus a 50% brand discount
Catastrophic Coverage Benefit:
   Generic/Preferred    Multi-Source Drug (3) $2.65 (3) $2.55 (3) $2.65 (3) $2.60 (3) $2.50 (3)
    Other Drugs (3) $6.60 (3) $6.35 (3) $6.60 (3) $6.50 (3) $6.30 (3)
Part D Full Benefit Dual Eligible (FBDE) Parameters: 2015 2014 2013 2012 2011
   Deductible $0.00 $0.00 $0.00 $0.00 $0.00
   Copayments for    Institutionalized    Beneficiaries $0.00 $0.00 $0.00 $0.00 $0.00
Maximum Copayments for Non-Institutionalized Beneficiaries
    Up to or at 100% FPL:
        Up to Out-of-Pocket Threshold
      Generic/Preferred       Multi-Source Drug $1.20 $1.20 $1.15 $1.10 $1.10
      Other $3.60 $3.60 $3.50 $3.30 $3.30
     Above Out-of-Pocket      Threshold $0.00 $0.00 $0.00 $0.00 $0.00
    Over 100% FPL:
        Up to Out-of-Pocket Threshold
      Generic/Preferred       Multi-Source Drug $2.65 $2.55 $2.65 $2.60 $2.50
      Other $6.60 $6.35 $6.60 $6.50 $6.30
     Above Out-of-Pocket      Threshold $0.00 $0.00 $0.00 $0.00 $0.00
Part D Full Subsidy – Non Full Benefit Dual Eligible Full Subsidy Parameters: 2015 2014 2013 2012 2011
Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources < $8,580 (individuals) or < $13,620 (couples) (4)
   Deductible $0.00 $0.00 $0.00 $0.00 $0.00
    Maximum Copayments up to Out-of-Pocket Threshold
      Generic/Preferred       Multi-Source Drug $2.65 $2.55 $2.65 $2.60 $2.50
      Other $6.60 $6.35 $6.60 $6.50 $6.30
   Maximum Copay above    Out-of-Pocket    Threshold $0.00 $0.00 $0.00 $0.00 $0.00
Partial Subsidy Parameters: 2015 2014 2013 2012 2011
Applied and income below 150% FPL and resources between $8,581-$13,300 (individuals) or $13,621-$26,580 (couples) (category code 4) (4)
   Deductible $66.00 $63.00 $66.00 $65.00 $63.00
   Coinsurance up to    Out-of-Pocket    Threshold 15% 15% 15% 15% 15%
    Maximum Copayments above Out-of-Pocket Threshold
      Generic/Preferred       Multi-Source Drug $2.65 $2.55 $2.65 $2.60 $2.50
      Other $6.60 $6.35 $6.60 $6.50 $6.30

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(1) Total Covered Part D Spending at Out-of-Pocket Threshold for Non-Applicable Beneficiaries – Beneficiaries who ARE entitled to an income-related subsidy under section 1860D-14(a) (LIS)
(2) Total Covered Part D Spending at Out-of-Pocket Threshold for Applicable Beneficiaries – Beneficiaries who are NOT entitled to an income-related subsidy under section 1860D-14(a) (NON-LIS) and do receive the coverage gap discount. For 2015, the weighted gap coinsurance factor is 90.693%. This is based on the 2013 PDEs (85.9% Brands & 14.1% Generics)
(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2015, beneficiaries would be charged $2.60 for those generic or preferred multisource drugs with a retail price under $52 and 5% for those with a retail price greater than $52. As to Brand drugs, beneficiaries would pay $6.60 for those drugs with a retail price under $132 and 5% for those with a retail price over $132.
(4) The actual amount of resources allowable may be updated for contract year 2015.

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