Health Insurance Medicare Print How Much Does Medicare Part D Cost? Understanding the Donut Hole and More By Tanya Feke, MD Updated June 02, 2019 Medically reviewed by a board-certified physician Medicare Part D Overview Eligibility Coverage Costs Enrollment Alternatives In This Article Table of Contents Expand Creditable Coverage Premiums Deductibles Copayments vs. Coinsurance IRMAA Late Penalties The Donut Hole Catastrophic Coverage Closing the Donut Hole View All Before Part D began in 2006, Medicare beneficiaries spent an average of $2,318 out of pocket on their medications. After Part D, prescription drug coverage, while not free, did become more manageable for seniors. Out of pocket expenses are now associated with premiums, deductibles, copayments, and coinsurance. It is important to understand the costs associated with Part D plans so you can budget your health care. To do that, you need to learn some lingo and how costs are spread across various categories. Illustration by Brianna Gilmartin, Verywell Creditable Prescription Drug Coverage The Centers for Medicare and Medicaid Services (CMS) requires Part D plans to offer at least two medications in each of 146 different drug classes. In addition, they have six classes of medications—anticonvulsants, antidepressants, antipsychotics, cancer drugs, HIV/AIDS drugs, and immunosuppressant drugs—where most, if not all, medications have to be covered. These rules, among others, set a standard that is known as creditable coverage. Examples of plans with creditable coverage include the Federal Employee Health Benefits (FEHB) Program, Indian Health Service, TRICARE (military benefits), and Veterans Benefits. Many private insurance plans and even some Health Insurance Marketplace plans, like Obamacare plans, do not have creditable coverage. This is an important factor to consider when you decide you want a Part D plan. Not having creditable coverage could cost you in late fees if you miss signing up for Part D during appropriate times. Premiums A premium is a dollar amount you pay every month for your Part D plan. These premiums do not pay towards any of your medications but pay for the benefit of having prescription drug coverage. If you do not pay your premiums, you will be dropped from the plan and end up with no coverage at all. Although each insurance company sets their own premium rates, the government sets a standard premium amount known as the national base beneficiary premium (NBBP) every year. In 2019, the NBBP is $33.19. The NBBP is not an arbitrary number. It is used to calculate how much you will pay in late fees, if they apply to you. Deductibles A deductible is the amount you pay out of pocket every year before you can use your prescription drug benefits. This cost is in addition to your monthly premiums. The Centers for Medicare and Medicaid Services (CMS) has rules in place to protect Medicare beneficiaries. Every year, CMS sets the highest amount an insurance company can charge you for a Part D deductible. The amount for 2018 was set at $405 but increased to $415 in 2019. Again, private insurance companies can set their own rates. Depending on what Part D plan you sign up for, you may have no deductible at all but you will pay no more than the rate set by the government. Copayments vs. Coinsurance Copayments (also referred to as copays) and coinsurance are what you actually pay for your prescription drugs. A copayment is a fixed dollar amount you pay while a coinsurance is a fixed percentage, not to exceed 25 percent, you pay for a prescription. Most of the time you will pay copays for your prescriptions. Copays and coinsurance may vary depending on what medications you take, costing less for generic medications and more for expensive brand name medications. Part D plans typically sort their formulary drugs into different tiers. The lower the tier, the lower the cost to you. There are no official rules in place for insurance companies to arrange their tiers. Some plans may have only three tiers, others as many as five or more. Example of Simple Tier System Example of Expansive Tier System 1. Generic drugs2. “Preferred” brand name drugs3. “Non-preferred” brand name drugs 1. “Value” generic drugs2. “Regular” generic drugs3. “Preferred” brand name drugs4. “Non-preferred” brand name drugs5. Specialty drugs and injectables Know that medications will increase in cost as you move to higher numbered tiers. Choosing medications in the lower tiers will keep your costs down. Another thing to keep in mind is that you cannot decrease how much you pay in copays and coinsurance by using manufacturer drug coupons. It is against the law, namely the Anti-Kickback Statute, to use a coupon from a pharmaceutical company while a federal program pays for that medication. In other words, you must choose between your Part D coverage or a drug coupon. You cannot use both. Income-Related Monthly Adjustment Amount (IRMAA) If you earn more than a certain amount every year, you will pay more for your Part D plan. Medicare, not the insurance company, charges you an extra fee every month known as the Part D income-related monthly adjustment amount (IRMAA). If you do not pay this extra amount to Medicare, your Part D plan will be canceled. How Much You Will Pay for Part D IRMAA Income on Individual Tax Return Income for Married Couples Filing a Joint Tax Return Income for Married Couples Filing Separately 2019 IRMAA Less than or equal to $85,000 Less than or equal to $170,000 Less than or equal to $85,000 $0.00 Greater than $85,000 and less than or equal to $107,000 Greater than $170,000 and less than or equal to $214,000 N/A $12.40 Greater than $107,000 and less than or equal to $133,500 Greater than $214,000 and less than or equal to $267,000 N/A $31.90 Greater than $133,500 and less than or equal to $160,000 Greater than $267,000 and less than or equal to $320,000 N/A $51.40 Greater than $160,000 and less than or equal to $500,000 Greater than $320,000 and less than or equal to $750,000 Greater than $85,000 and less than or equal to $415,000 $70.90 Greater than $500,000 Greater than $750,000 Greater than $415,000 $77.40 Medicare uses your income taxes from two years ago to decide your IRMAA payments every year. Late Penalties You can sign up for Part D when you become eligible for Medicare. You should understand and know about these three important enrollment periods. By age: When you turn 65 years old, your initial enrollment period for all Medicare parts starts three months before and ends three months after your 65th birthday.By disability: When you are on disability, you are automatically enrolled in Parts A and B after your 25th month of Social Security Disability Insurance benefits. You have three months to sign up for Part D.By employer: When you work for a company that hires 20 full-time employees or the equivalent and have an employer-sponsored health plan through that company, you have eight months from the time you leave that job or that health plan, whichever comes first, to apply for Medicare and Part D. When you miss one of these enrollment periods, you could end up paying late fees for Part D. This only applies if you do not have creditable drug coverage during the time you are eligible but are not enrolled in Part D. Medicare gives you only a little leeway. You have up to 63 days without creditable drug coverage before monthly late penalties will be charged. How Late Fees Are Calculated The late penalty is calculated as one percent of the national base beneficiary premium (NBBP) multiplied by the number of complete months you were without creditable drug coverage after you were eligible. It is rounded off to the nearest $0.10. For example, if you missed your initial enrollment period and went without creditable drug coverage for six complete months, your late penalty would be calculated as follows: $33.19 (NBBP for 2019) x 0.01 x 6 months = $2.00. Because the NBBP changes every year, the late penalty will change as well. The late penalty amount will change every year on January 1 and be added to your monthly premiums. The penalties continue as long as you have Part D with one exception. If your late penalties started before you met Medicare eligibility by age, they will stop when you turn 65. The Donut Hole When you hear the word donut, you may think of a tasty treat. When you look closer, you see that something is missing. There is a big hole in the middle. Medicare Part D has a coverage gap known as the donut hole. After you and your Part D plan pay a certain amount of money, your prescription drug coverage drops off, leaving you to pay more out of pocket. This lapse in coverage is short-term but could get expensive depending on the medications you take. Understanding Part D’s out of pocket expenses may help you to better manage your finances and perhaps avoid the donut hole altogether. Understanding the Coverage Gap Medicare’s Part D coverage is divided into three phases. Hopefully, you will never leave phase one since this is where you save the most money. Initial Coverage LimitThe Donut Hole (Coverage Gap)Catastrophic coverage The donut hole can be confusing if you do not know how the Part D coverage phase works. This overview will explain the rules and costs for each of these phases. Initial Coverage Limit The initial coverage limit is where you get most of your prescription drug coverage. In this phase, you will pay copays and coinsurance for your medications according to your Part D plan’s formulary and policies. Your out-of-pocket expenses at this time will include monthly premiums, deductibles, copays, and coinsurance. Not all of these costs, however, will count towards your initial coverage limit. Premiums, which may be a large part of your monthly spending, do not count. Other costs that do not count are costs of medications purchased outside of the U.S. or medications not covered by your Part D formulary. What your Part D plan pays towards your prescription drug coverage also counts towards the initial coverage amount. Your Part D plan will send you monthly summaries that review how much has been spent. In 2018, the initial coverage limit lasted until you and Medicare spent $3,750. In 2019, that value increased to $3,820. The larger the initial coverage limit, the better off you are. The annual increase is good news because it means more time will pass before the donut hole begins. The Donut Hole During the donut hole, your Part D plan’s copays and coinsurance are replaced by a one-size-fits-all payment plan. Manufacturers of brand name drugs are required to give you a 50 percent discount on their products. Of the costs that remain, you will pay a fixed percentage. This was 35 percent in 2018 and decreased to 25 percent for 2019. The remainder of the costs are paid by your Part D plan. For example, if a brand name drug costs $100, you will pay $25, the manufacturer will pay $50 and your Part D plan will pay $25. There is no manufacturer discount given for generic medications. You will pay 37 percent of those drug costs in 2019. For example, if a 2019 generic drug costs $100, you will pay $37, the manufacturer will pay $0 and your Part D plan will pay $63. Please note that generics rarely cost this much. These numbers were used to make it easier for you to understand how the math works. Similar to the initial coverage limit, not all costs will count towards your donut hole spending. Premiums, costs of medications purchased outside of the United States, costs of non-formulary medications, and money spent by your Part D plan do not count. Money spent by the manufacturer, however, will be added to your out-of-pocket tally and will help you get you out of the donut hole sooner. In 2019, you will remain in the donut hole until you and your Part D plan have spent a total of $5,100 on drugs for 2019, and when you take into account your initial coverage limit, it means $1,280 is spent in the donut hole. In 2020, the out-of-pocket threshold increases to $6,350 and the amount spent in the donut hole rises to $2,330. Catastrophic Coverage After you have made it through the donut hole, you may feel that you have been through a catastrophe—or at least your wallet has. It is no surprise the government has come to name the next phase of Part D as “catastrophic coverage.” The costs of copays and coinsurance during catastrophic coverage will not be the same as your initial coverage limit. Thankfully, they will be lower. For 2019, you would either pay a five percent coinsurance for each prescription or copayments of $3.40 for generic drugs and $8.50 for brand name drugs. You will be required to pay the option that costs you more. The five percent coinsurance continues for 2020 but the copayments for generic and brand name drugs will increase to $3.60 and $8.95, respectively. Closing the Donut Hole When Part D came into effect in 2006, there was no prescription drug coverage during the donut hole. The donut hole was truly that, an empty space. Since that time, healthcare reform has taken efforts to decrease the cost burden to Medicare beneficiaries. One of the goals of the Affordable Care Act, aka Obamacare, is to close the donut hole. A plan is now in place to decrease the costs of drugs to 25 percent, both generic and brand name, by 2020. Donut Hole Costs Through 2020 Year What You Pay for Brand Name Drugs (%) Manufacturer Discount for Brand Name Drugs (%) What Part D Pays for Brand Name Drugs (%) What You Pay for Generic Drugs (%) What Part D Pays for Generic Drugs (%) 2015 45 50 5 65 35 2016 45 50 5 58 42 2017 40 50 10 51 49 2018 35 50 15 44 56 2019 30 50 20 37 63 2020 25 50 25 25 75 Twenty-five percent of drug costs is the standard set by the Centers for Medicare and Medicaid Services for the initial coverage limit. Essentially, the initial coverage limit and donut hole will flow into one another once these changes take effect. Catastrophic coverage will remain in place to protect you against excessive out of pocket costs. How to Enroll in Medicare Part D Was this page helpful? Thanks for your feedback! Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Email Address Sign Up There was an error. Please try again. Thank you, , for signing up. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Medicare Drug Coverage under Medicare Part A, Part B, Part C, & Part D. Centers for Medicare and Medicaid Services. https://www.cms.gov/outreach-and-education/outreach/partnerships/downloads/11315-p.pdf Drug coverage (Part D). Centers for Medicare and Medicaid Services. https://www.medicare.gov/drug-coverage-part-d Costs in the Coverage Gap. Centers for Medicare and Medicaid Services. https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html. Continue Reading How Much Money Will Be Eaten Up by the Medicare Part D Donut Hole How Much Medicare Part D Will Cost You in 2019 Here's What You Need to Know About the Medicare Part D Coverage Gap How to Enroll in Medicare Part D How to Lower Your Drug Costs in the Donut Hole How to Enroll in a Medicare Part D Drug Plan Medicare Part D Penalty: What It Is and How to Avoid It What Will Happen If Medicare Part B Drug Coverage Moves to Part D? An Overview of Medicare Eligibility and Benefits An Overview of Prescription Drug Insurance Where to Get Help Choosing a Medicare Part D Drug Plan Alternatives to Medicare Part D Why You Can't Use Drug Coupons With Medicare Part D What Is Medicare Part D? 5 Mistakes People Make During Medicare Open Enrollment What Does Medicare Part D Cover?