Medicare Part D potential benefits
The charts below can help you determine your potential out-of-pocket costs for the new Medicare Part D coverage.
To determine your estimated costs use the column that reflects your annual household income. The appropriate column will show your
expected annual Medicare Part D premium, your co-pay for medications, and your share of annual drug costs (based upon your annual
individual drug costs).
Married | Single
Benefits for
Annual household
income
Less than
$13,250
$13,250 -
$17,887
$17,888 -
$19,875
Greater than
$19,875
Estimated annual Medicare Part D Premium
Free
Free
$0 - $420
$420 or higher
Co-pay
$1 generic
$2 generic
Based on deductible & co-insurance responsibilities
Based on deductible & co-insurance responsibilities
Annual individual drug cost
Your share of annual drug costs (excluding premium)
$50
$1
$1
$40
$40
$100
$3
$6
$54
$80
$200
$4
$7
$66
$160
$400
$9
$15
$90
$267
$800
$19
$34
$138
$347
$1,200
$28
$49
$186
$427
$1,600
$37
$64
$234
$507
$2,400
$56
$98
$330
$667
$3,200
$75
$132
$426
$1,060
$4,000
$93
$162
$522
$1,700
$4,800
$112
$196
$618
$2,340
$5,500
$128
$224
$702
$2,900
$11,000
$256
$448
$1,362
$3,789
$22,000
$513
$897
$2,682
$4,240
To determine annual out-of-pocket drug costs, add your estimated annual Medicare Part D Premium and your share of annual drug
costs.
Benefits for
Annual household
income
Less than
$10,295
$10,295 -
$13,896
$13,897 -
$15,441
Greater than
$15,441
Estimated annual Medicare Part D Premium
Free
Free
$0 - $420
$420 or higher
Co-pay
$1 generic
$2 generic
Based on deductible & co-insurance responsibilities
Based on deductible & co-insurance responsibilities
Annual individual drug cost
Your share of annual drug costs (excluding premium)
$50
$1
$1
$40
$40
$100
$3
$6
$54
$80
$200
$4
$7
$66
$160
$400
$9
$15
$90
$267
$800
$19
$34
$138
$347
$1,200
$28
$49
$186
$427
$1,600
$37
$64
$234
$507
$2,400
$56
$98
$330
$667
$3,200
$75
$132
$426
$1,060
$4,000
$93
$162
$522
$1,700
$4,800
$112
$196
$618
$2,340
$5,500
$128
$224
$702
$2,900
$11,000
$256
$448
$1,362
$3,789
$22,000
$513
$897
$2,682
$4,240
To determine annual out-of-pocket drug costs, add your estimated annual Medicare Part D Premium and your share of annual drug
costs.
