On this page we list the standouts from the CMS-defined Standard Benefit plan (I.e. the minimum-allowable plan offered) changes between 2015 and 2016. In the table below, we’ve included the Standard Benefit changes for 2012 – 2016.
- Initial Deductible:
- To increase by $40 to $360 in 2016.
- Initial Coverage Limit:
- To be increased from $4,700 in 2015 to $4,850 in 2016.
- Out of Pocket Threshold:
- Will be increasing from $4,700 in 2015 to $4,850 in 2016.
- Coverage Gap (donut hole):
- Starts when reaching one’s Medicare Part D initial coverage limit ($3,310 in 2016) and stops when spending a total of $4,850 in 2016.
In 2016, those enrolled in Medicare Part D are to receive a 55-percent discount on the total expense of their brand name drugs purchased during the donut hole. This discount is paid by the brand name Rx drugs manufacturers and applies to exiting the donut hole. With that said, the added 5% covered by one’s Medicare Part D plan does not go toward TrOOP.
To give you an example, should you enter the donut hole and buy a brand name Rx drug at a retail price of $100, you will then pay $45 for the Rx drug and receive a $95 credit that goes toward reaching your 2016 total out of pocket spending limit.
Those enrolled pay a max 58% copay on generic Rx drugs bought during the coverage gap (discounted 42%). As an example, someone who reaches the 2016 Donut Hole, and their Rx drug carries a retail price of $100, they will then pay $58, which counts toward their TrOOP.
- Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit**:
- Will be increasing to 5% or $2.95 (whichever is greater) for generic or preferred Rx drugs that are multisource and 5% or $7.40 (whichever is greater) for every other type of Rx drug in 2016.
- Maximum Co-payments below the Out of Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees:
- Will be increasing to $2.95 for generic of preferred Rx drugs that are multisource and $7.40 for every other type of Rx drug in 2016.
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