Key Medicare Parts A & B Coverage Gaps (2022)

Medicare Supplements

Plan F’s benefits cover all deductibles and coinsurances above.

Plan G is the same as Plan F except its does not pay the Part B Deductible (see table above).

Plan N is similar to Plan G – has copays for doctor visits ($20) and ER visits ($50) – additional costs if non-participating providers are used.

The deductible for High Deductible Plans F & G is $2490 (2021: $2370, 2020: $2340) (not to be confused with standard Plan F & G)

Part D – Overview

  • Prescription max limits
    • Max Deductible: $480 (2021: $445, 2020: $435, 2019:$415)
    • Initial Coverage Limit: $4430 (2021: $4130, 2020: $4020, 2019:$3820) – copays apply
  • Coverage Gap “Donut Hole” (after Initial Coverage Limit has been met)
  • Out-of-Pocket Threshold (The point at which you exit the donut hole): $7050 (2021: $6550, 2020: $6350, 2019: $5100)
  • Catastrophic Drug benefits (after the donut hole)
    • Generic/Preferred Multi-Source Drugs – $3.95 for those with retail price under $79. 5% for those with retail price over $79.
    • Brand Name Drugs – $9.85 for those with retail price under $197. 5% for those with retail price over $197.
  • See our Part D Page for information on purchase and annual review.
    http://www.deesigned.com/medicare/medicare-part-d/
  • “Medicare and You”: https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf

Medicare home page https://www.medicare.gov/

Part D – A Simplified Explanation

Below is Dee-Signed’s simplified explanation of Medicare Part D Benefits 2019 (Not a legal interpretation)

First, a definition
True Out-of-Pocket (TrOOP) is a term used to refer to all the monies you have spent (as well as some bonus credits from name brand drugs taken in the Coverage Gap “donut hole”) towards the $5100 limit where you leave the Coverage Gap “donut hole” and enter Catastrophic Coverage.

In a nutshell: Your portion of the $7,050 TrOOP required to reach catastrophic coverage, is reduced by 75% of the cost of brand-name drugs purchased while in the “Donut Hole”.

Annually, there are four “phases” of Medicare Part D, each handles prescription costs differently.

Phase 1: Deductible
You pay $0 to $480 depending on plan, amount you pay added to TrOOP.

Phase 2: Initial Coverage
You pay copays until you and insurance have paid $4,430 for the year. Your copays are added to TrOOP.

Phase 3: Coverage Gap (Donut Hole)
Generic Drugs: You pay 25% – that amount is added to TrOOP
Name Brand Drugs: You pay 25% – that amount is added to TrOOP. ADDITIONALLY 75% of the drugs’ costs are credited to TrOOP.

You exit the Coverage Gap when your TrOOP equals $7050 via monies you’ve paid this calendar year and the special 75% brand name donut hole drug credits mentioned above.

Phase 4: Catastrophic Coverage (After Donut Hole)

  • Generic/Preferred Multi-Source Drugs – $3.95 for those with retail price under $79. Otherwise, 5% for those with retail price over $79.
  • Brand Name Drugs – $9.85 for those with retail price under $197. Otherwise, 5% for those with retail price over $197.
  • NO LIMIT