A portion of the $1,500 retail cost will fall into the Initial Deductible - and the remainder of the cost will fall into the Initial Coverage Phase. This is called a “straddle claim”.
Lets say that your plan has a $320 Deductible and that your $1,500 medication has a 33% coinsurance and you have already purchased $100 worth of medications -- your remaining Deductible would be $220. You would pay the following:
$220 of the $1,500 would go toward your Deductible. This would leave $1,280 that falls into your Initial Coverage phase where you have 33% coinsurance on this medication.
Your coinsurance for the portion that falls into the Initial Coverage phase is $422.40 ($1,280 x.33).
The total cost-sharing to be paid by you would be $642.40 ($220 + $422.20).
Straddle claims are not reported very clearly on your Explanation of Benefits. You can also contact your plan's Member Services department for an explanation of a specific purchase.
To see other straddle claim examples, please on this site
Lets say that your plan has a $320 Deductible and that your $1,500 medication has a 33% coinsurance and you have already purchased $100 worth of medications -- your remaining Deductible would be $220. You would pay the following:
$220 of the $1,500 would go toward your Deductible. This would leave $1,280 that falls into your Initial Coverage phase where you have 33% coinsurance on this medication.
Your coinsurance for the portion that falls into the Initial Coverage phase is $422.40 ($1,280 x.33).
The total cost-sharing to be paid by you would be $642.40 ($220 + $422.20).
Straddle claims are not reported very clearly on your Explanation of Benefits. You can also contact your plan's Member Services department for an explanation of a specific purchase.
To see other straddle claim examples, please on this site
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