Key Medicare Parts A & B Coverage Gaps
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 $2700 (2022: $2490, 2021: $2370, 2020: $2340) (not to be confused with standard Plan F & G)
Part D – Overview
- Prescription max limits
- Max Deductible: $505 (2022: $480, 2021: $445, 2020: $435, 2019:$415)
- Initial Coverage Limit: $4460 (2022: $4430, 2021: $4130, 2020: $4020, 2019:$3820) – copays apply
- Entire retail costs of drugs go toward the Initial Coverage Limit, not just the copays.
- Coverage Gap “Donut Hole” (after Initial Coverage Limit has been met)
- Brand Name drugs will have a ~75% discount. (~95% of drugs’ total costs count toward your OOP.)
- Generic drugs will receive a ~75% discount. (The ~25% that you spend counts toward your OOP.)
- Out-of-Pocket Threshold (The point at which you exit the donut hole): $7400 (2022: $7050, 2021: $6550, 2020: $6350, 2019: $5100)
- Catastrophic Drug benefits (after the donut hole)
- Generic/Preferred Multi-Source Drugs – $4.15 for those with retail price under $83. 5% for those with retail price over $83.
- Brand Name Drugs – $10.35 for those with retail price under $207. 5% for those with retail price over $207.
- See our Part D Page for information on purchase and annual review.
- “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 $7,400 TrOOP required to reach catastrophic coverage, is reduced by 70-75% 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 $505 depending on plan, amount you pay added to TrOOP.
Phase 2: Initial Coverage
You pay copays until you and insurance have paid $4,660 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 $7400 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 – $4.15 for those with retail price under $83. Otherwise, 5% for those with retail price over $83.
- Brand Name Drugs – $10.35 for those with retail price under $207. Otherwise, 5% for those with retail price over $207.
- NO LIMIT