CMS Part D 2017 Standard Benefit Model Plan Feature Highlights

Here are the highlights for the CMS defined Standard Benefit Plan changes from 2016 to 2017. The chart below shows the Standard Benefit design changes for plan years 2013, 2014, 2015, 2016 and 2017. This "Standard Benefit Plan" is the minimum allowable plan to be offered.

• Initial Deductible: will be increased by $40 to $400 in 2017.

• Initial Coverage Limit: will increase from $3,310 in 2016 to $3,700 in 2017.

• Out-of-Pocket Threshold: will increase from $4,850 in 2016 to $4,950 in 2017.

• Coverage Gap (donut hole): begins once you reach your Medicare Part D plan’s initial coverage limit ($3,700 in 2017) and ends when you spend a total of $4,950 in 2017.
In 2017, Part D enrollees will receive a 60% discount on the total cost of theirbrand-name drugs purchased while in the donut hole. The 50% discount paid by the brand-name drug manufacturer will apply to getting out of the donut hole, however the additional 10% paid by your Medicare Part D plan will not count toward your TrOOP.
For example: if you reach the donut hole and purchase a brand-name medication with a retail cost of $100, you will pay $40 for the medication, and receive $90 credit toward meeting your 2017 total out-of-pocket spending limit.
Enrollees will pay a maximum of 51% co-pay on generic drugs purchased while in the coverage gap (a 49% discount). For example: If you reach the 2017 Donut Hole, and your generic medication has a retail cost of $100, you will pay $51. The $51 that you spend will count toward your TrOOP.

• Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**: will increase to greater of 5% or $3.30 for generic or preferred drug that is a multi-source drug and the greater of 5% or $8.25 for all other drugs in 2016.

• Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $3.30 for generic or preferred drug that is a multi-source drug and $8.25 for all other drugs in 2017.

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What discount can we expect in the Doughnut Hole

October 2016 - Starting back in the 2011 Medicare Part D plan year, a discount or co-insurance (cost-sharing) was introduced to reduce the cost of generic and brand-name prescription drugs purchased by non-LIS Medicare beneficiaries once they entered the Coverage Gap (or Donut Hole / Doughnut Hole) portion of their Medicare Part D prescription drug plan.

If you reach the Donut Hole phase of your Medicare prescription drug plan and your medication is on your plan's formulary and you are not receiving financial Extra Help:

• In 2017, you will receive a 60% discount on Brand-name drugs and a 49% discount on Generic drugs. (You will pay 40% of your plan's negotiated retail cost for brand-name prescriptions and 51% of the retail cost for generics.

• In 2016, you receive a 55% discount on Brand-name drugs and a 42% discount on Generic drugs. (You will pay 45% of your plan's negotiated retail cost for brand-name prescriptions and 58% of the retail cost for generics.)

Please see the charts below for Donut Hole discounts up to 2020.

Please note: The Donut Hole discount is not available to anyone receiving financial Extra Help (the Low-Income Subsidy). Also, the Donut Hole discount is only for Medicare Part D drugs included on your Medicare prescription drug plan's formulary or drug list.

The Generic drug discount will increase each year until the plan year 2020 when the co-insurance for generics in the Coverage Gap will be 25%. The following table shows how the annual Generic drug discount increases:


Generic Drug Discount

Plan Year Beneficiary Cost-Sharing Plan Cost-Sharing
2011 93% 7%
2012 86% 14%
2013 79% 21%
2014 72% 28%
2015 65% 35%
2016 58% 42%
2017 51% 49%
2018 44% 56%
2019 37% 63%
2020 25% 75%


The Brand-name drug discount operates differently from the Generic drug discount - but the Brand-Name drug discount will also be reduced to co-insurance of 25% by 2020.


Brand-Name Drug Discount

Plan Year Beneficiary Cost-Sharing Plan Cost-Sharing Manufacturer Cost-Sharing
2011 50% 0% 50%
2012 50% 0% 50%
2013 47.5% 2.5% 50%
2014 47.5% 2.5% 50%
2015 45% 5% 50%
2016 45% 5% 50%
2017 40% 10% 50%
2018 35% 15% 50%
2019 30% 20% 50%
2020 25% 25% 50%

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