Note: The amounts in this table do not apply to beneficiaries who have the Part D Low Income Subsidy (“Extra Help”)
Annual Deductible Maximum | $400 |
Initial Coverage Period Cost sharing during this period may be a flat 25% co-insurance OR the plan may have a tiered system of co-pays and co-insurance that is actuarially equivalent to 25% | |
Initial Coverage Limit (Once the member AND the plan have spent this amount, the member enters the Donut Hole) | $3,700 |
Donut Hole During this period the member pays reduced costs for both generic and brand name drugs. On brand name drugs the member receives a 50% manufacturer discount and a further 10% subsidy from Medicare. On generic drugs the member receives a 49% subsidy from Medicare. The full cost of brand name drugs, minus the subsidy, counts toward TROOP (90%); the price paid for generic drugs (51%) counts also counts toward TROOP. | |
Catastrophic Coverage Threshold Catastrophic coverage begins when the member’s true out-of-pocket (TROOP) costs equals this amount. | $4,950 |
Total member spending before Catastrophic Coverage | $7,425 |
Cost sharing during Catastrophic Coverage | $3.30 (generics) / $8.25 (brand name) OR 5%, whichever is greater |
2. 2017 Low Income Subsidy (LIS) Co-Pay Amounts
| Generics Co-pay | Brand Name Co-Pay | Deductible |
Institutionalized FBDE or on HCBS waiver program | $0 | $0 | $0 |
FBDE at or below 100% FPL | $1.20 | $3.70 | $0 |
FBDE over 100% FPL | $3.30 | $8.25 | $0 |
Full Subsidy (up to 135% FPL) | $3.30 | $8.25 | $0 |
Partial Subsidy (up to 150% FPL) | 15% | 15% | $82 |
3. 2017 Total Donut Hole Discounts: 60% – brand name (50% + 10%); 49% – generic
4. 2017 Average Monthly Premium: $34.00
5. 2017 LIS Benchmark Threshold in Connecticut: $34.83
6. 2017 National Base Beneficiary Premium: $35.63 (used to calculate Part D Late Enrollment Penalty and income-related monthly adjustment amounts [IRMAA])
7. 2017 IRMAA threshold amounts: $85,000 single, $170,000 couples
8. 2017 Medicare Advantage MOOPs: in-network, 6,700; in and out-of- network combined – $10,000