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Chart Comparing 2012 through 2016 Standard Benefit Model Plan Features

Medicare Part D Benefit Parameters for Defined Standard Benefit
2012 through 2016 Comparison
Part D Standard Benefit Design Parameters: 2016 2015 2014 2013 2010
Deductible – (after the Deductible is met, Beneficiary pays 25% of covered costs up to total prescription costs meeting the Initial Coverage Limit. $360 $320 $310 $325 $320
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) $3,310 $2,960 $2,850 $2,970 $2,930
Out-of-Pocket Threshold – This is the Total Out-of-Pocket Costs including the Donut Hole. $4,850 $4,700 $4,550 $4,750 $4,700
Total Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap – for Persons Qualifying For LIS – and are not eligible for the donut hole discount.
Catastrophic Coverage starts after this point.See note (1) below.
$7,062.50 (1) $6,680.00 (1) $6,455.00 (1) $6,733.75 (1) $6,657.50 (1)
Total Estimated Covered Part D Drug Out-of-Pocket Spending including the Coverage Gap Discount (NON-LIS)See note (2). $7,515.22plus a 55% brand discount $7,061.76plus a 55% brand discount $6,690.77plus a 52.50% brand discount $6,954.52plus a 52.50% brand discount $6,730.39plus a 50% brand discount
Average NON-LIS percentage brand and generic drug purchases made during the coverage gap used to estimate the Total Covered Part D OOP threshold for NON-LIS beneficiaries (see above). Brand: 84.6%
Generic: 15.4%
Brand: 85.9%
Generic: 14.1%
Brand: 86.2%
Generic: 13.2%
Brand: 85.6%
Generic: 14.4%
Brand: 86.3%
Generic: 13.7%
Catastrophic Coverage Benefit:
   Generic/Preferred
Multi-Source Drug
(3)
$2.95 (3) $2.65 (3) $2.55 (3) $2.65 (3) $2.60 (3)
    Other Drugs (3) $7.40 (3) $6.60 (3) $6.35 (3) $6.60 (3) $6.50 (3)
Part D Full Benefit Dual Eligible (FBDE) Parameters: 2016 2015 2014 2013 2012
   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 $1.20 $1.15 $1.10
      Other $3.60 $3.60 $3.60 $3.50 $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
$2.95 $2.65 $2.55 $2.65 $2.60
      Other $7.40 $6.60 $6.35 $6.60 $6.50
     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: 2016 2015 2014 2013 2012
Eligible for QMB/SLMB/QI, SSI or applied and income at or below 135% FPL and resources < $8,780 (individuals) or < $13,930 (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
$2.95 $2.65 $2.55 $2.65 $2.60
      Other $7.40 $6.60 $6.35 $6.60 $6.50
   Maximum Copay above
Out-of-Pocket
Threshold
$0.00 $0.00 $0.00 $0.00 $0.00
Partial Subsidy Parameters: 2016 2015 2014 2013 2012
Applied and income below 150% FPL and resources between $8,780-$13,640 (individuals) or $13,930-$27,250 (couples) (category code 4) (4)
   Deductible $74.00 $66.00 $63.00 $66.00 $65.00
   Coinsurance up to
Out-of-Pocket
Threshold
15% 15% 15% 15% 15%
    Maximum Copayments above Out-of-Pocket Threshold
      Generic/Preferred
Multi-Source Drug
$2.95 $2.65 $2.55 $2.65 $2.60
      Other $7.40 $6.60 $6.35 $6.60 $6.50
Retiree Drug Subsidy Amounts: 2016 2015 2014 2013 2012
      Cost Threshold $360 $320 $310 $325 $320
      Cost Limit $7,400 $6,600 $6,350 $6,600 $6,500
(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 2016, the weighted gap coinsurance factor is 89.234%. This is based on the 2014 PDEs (84.6% Brands & 15.4% Generics)
(3) The Catastrophic Coverage is the greater of 5% or the values shown in the chart above. In 2016, beneficiaries will be charged $2.95 for those generic or preferred multisource drugs with a retail price under $59 and 5% for those with a retail price greater than $59. As to Brand drugs, beneficiaries would pay $7.40 for those drugs with a retail price under $148 and 5% for those with a retail price over $148.
(4) The actual amount of resources allowable may be updated for contract year 2016.