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How the Model Medicare Part D Plans Work?

Most basic or model Medicare Part D plans are broken down into three main parts:

  • initial deductible (assuming the plan does not have "first dollar coverage" or no initial deductible)
  • Beneficiary co-insurance or co-payment
  • Coverage Gap or Donut Hole (Beneficiary pays 100%) (assuming that the plan does not provide some coverage for this gap
  • Catastrophic Coverage
The CMS base plan works as follows:

Your out of pocket prescription drug costs are calculated on a progressive basis (like your federal income tax).

You will pay the first $250 yourself (as the Medicare Part D Plan deductible). After your deductible, you will pay 25% co-insurance towards all your prescription drug costs up to a total of $2,250.

For example, let us assume that your total yearly prescription drug expenses are $2,600.
Therefore, you will pay 25% of the difference between the deductible ($250) and $2,250 which is: (2,250 - 250)*.25 = $500.
When your costs total more than $2,250, you will be responsible for 100% of the difference between $2,250 and (as in our example) $2,600 or an additional cost of $350.

Your total ESTIMATED annual "Out of Pocket" prescription drug cost with a Medicare Part D plan should then be around: $250 + $500 + $350 = $1100
(plus the monthly premiums for the Medicare Part D plan).
 

 

Still not sure? See our Online Cost Estimator Example:

 

 



 

 

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