The out-of-pocket cost for medications can fluctuate throughout the year based on the following tiers. There will be some changes to drug coverage in 2023, and this will hopefully help you understand how you may be impacted.
Please keep in mind that actual 2023 plan options and benefit details will be available for your review beginning October 1, 2022.
Member pays 100% of the drug costs (if applicable) until they reach their annual deductible. Most plan deductibles in 2023 will be $505, but some Part D plans may have lower or $0 deductibles. These plans, however, tend to have higher monthly premiums. If your plan does not have a deductible, your coverage will begin in the Initial Coverage Tier (Tier 2).
Members pay cost-share until the total costs of drugs reach the Initial Coverage Limit (ICL). The ICL includes everything the member and plan play. Until the total drug costs reach $4,660 (increased from $4,430 in 2022).
Member pays 25% coinsurance for generic and brand-name drugs. This tier is often referred to as the “Donut Hole”. Until the total out-of-pocket reaches $7,400 (increased from $7,050 in 2022).
You will receive a 75% discount on the total cost of all brand-name drugs that are purchased while in the Donut Hole. This discount includes a 70% discount paid by the brand-name manufacturer and a 5% discount paid by your Medicare Part D plan. The 70% that is paid by the drug manufacturer is combined with the 25% that you pay, and that counts towards your true out-of-pocket (TrOOP).
If you reach the Donut Hole, you will receive a discount of 75% on generic drugs and pay a maximum of 25% copay on generic drugs that are purchased while in the coverage gap.
Member is responsible for the greater of 5% coinsurance or $4.15 generic copay and $10.35 brand-name copay. Until the end of the calendar year.
True out-of-pocket (TrOOP) costs are the expenses that count toward a person’s Medicare drug plan out-of-pocket threshold. TrOOP costs determine when a person’s catastrophic coverage will begin. The drug plan keeps track of each member’s TrOOP costs.
For 2023, the TrOOP amount is $7,400 (increased from $7,050 in 2022). Drug plans will provide a monthly explanation of benefits (EOB) that shows TrOOP costs to date.
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