The Donut Hole
Here are the highlights for the CMS defined Standard Benefit Plan changes from 2015 to 2016. The chart below shows the Standard Benefit design changes for plan years 2012, 2013, 2014, 2015 and 2016. This “Standard Benefit Plan” is the minimum allowable plan to be offered.
- Initial Deductible:
will be increased by $40 to $360 in 2016.
- Initial Coverage Limit:
will increase from $2,960 in 2015 to $3,310 in 2016.
- Out-of-Pocket Threshold:
will increase from $4,700 in 2015 to $4,850 in 2016.
- Coverage Gap (donut hole):
begins once you reach your Medicare Part D plan’s initial coverage limit ($3,310 in 2016) and ends when you spend a total of $4,850 in 2016.
In 2016, Part D enrollees will receive a 55% 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 5% 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 $45 for the medication, and receive $95 credit toward meeting your 2016 total out-of-pocket spending limit.
Enrollees will pay a maximum of 58% co-pay on generic drugs purchased while in the coverage gap (a 42% discount). For example: If you reach the 2016 Donut Hole, and your generic medication has a retail cost of $100, you will pay $58. The $58 that you spend will count toward yourTrOOP.
- Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**:
will increase to greater of 5% or $2.95 for generic or preferred drug that is a multi-source drug and the greater of 5% or $7.40 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 $2.95 for generic or preferred drug that is a multi-source drug and $7.40 for all other drugs in 2016.