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Phil Dougherty, President, OHI



2020 Benchmark for Medicare Prescription Drug Coverage
(Part D)

Last updated October 2018

Below is the defined standard benefit model as set by Centers for Medicare and Medicaid Services (CMS) for the 2019 plan year. All plans must include these Coverage Stages and provide benefits as good as or better than those shown.

Part D Coverage Levels

What You Pay

Coverage Stages

Deductible 100% $0 to $415
Initial Coverage Period 25% After deductible and until total prescription drug costs reach $3,820*
Coverage Gap (Donut Hole) Brands
(75% discount)
70% paid by drug company
25% Paid by member
5% Paid by Plan
63% Paid by Plan
37% Paid by member
Starts when total yearly drug costs reach $3,820 and until your yearly out-of-pocket drug costs reach $5,100
Catastrophic Coverage $3.40 for generic / $8.50 Brand
or 5%, whichever is greater
Starts after your out-of-pocket drug expenses reach $5,100 and runs through the rest of the calendar year

*Coverage Gap: In 2020, Part D enrollees will receive a 75% discount on the total cost of their brand-name drugs purchased while in the donut hole. The discount includes, 70% discount paid by the brand-name drug manufacturer and will apply to getting you out of the donut hole, however the additional 5% paid by your Medicare Part D plan will not count toward your out of pocket (known as TrOOP or True Out of Pocket). Also, Medicare Part D beneficiaries will receive a 63% discount on generic drugs purchased while in the donut hole and the 37% spent by the beneficiary will count towards their TrOOP.