The standard 2018 Medicare Part D prescription drug coverage is as follows. Note: your individual plan may differ, but must at a minimum meet this standard level of coverage. Your plan may have other changes that will be mailed to you in the Annual Notification of Change ANOC that you should receive late September.
The Initial Deductible will be increasing from $400 to $405 for 2018. This means the first $405 will be paid by the insured (you) before the plans cost-sharing begins. There may be a plan available without a deductible, but the highest deductible a plan can have for 2018 is $405. Also, some plans exclude Tier 1 and Tier 2 generic prescriptions from the deductible.
The Initial Coverage Limit will be increased from $3,700 to $3,750. This is the limit when an individual will enter the Coverage Gap (doughnut Hole). This is the negotiated retail value of your prescriptions. So if a medication has a $50 negotiated retail cost, but on your plan it costs you $4 to fill, the $50 cost is used to reach the Initial Coverage Limit. In 2018 if your monthly average retail cost of prescriptions is $312 or less you will not go into the Coverage Gap.
In 2018 the Coverage Gap costs will continue to shrink for individuals that go into the Coverage Gap. For 2018 people in the Coverage Gap (Doughnut Hole) will receive a 56% discount on generic prescriptions, so if a generic prescriptions retail cost is $10 you will pay $4.40 for that prescription or 44% of the retail cost. The $4.40 is the amount used to get an individual out of the Coverage Gap when calculating TrOOP or Total out of Pocket Costs
The discount for Brand Name prescriptions will increase from 60% to 65% for 2018, 50% of this from the manufacturers discount. So people in the Coverage Gap will pay 35% of the negotiated retail price for brand name prescriptions. So you will pay $35 for a brand name drug with a retail cost of $100. Individuals in the Coverage Gap will receive credit for 85% of the cost towards their TrOOP (Total out Of Pocket) costs. This is by adding the 35% the individual pays plus the 50% manufacturer’s discount.
In 2018 the Total Out-of-Pocket costs TrOOP will increase from $4,950 to $5,000. This is the amount that you must spend (or have spent for you i.e. Manufacturers discount) to get out of the Coverage Gap (Doughnut Hole). SO in the coverage Gap your copay plus the 50% manufacturers’ discount of 50% will count towards this number. When an individual reached the TrOOP they will leave the Coverage Gap and enter Catastrophic Coverage
Catastrophic Coverage is the final phase of your Prescription Drug Plan (PDP). In this phase an individual will pay the greater of $3.35 or 5% of the retail cost for generics, and $8.35 or 5% of the retail cost for Brand name prescriptions. This phase will last until December 31st when the 2019 Plan begins.