Frequently Asked Questions about Straddle Claims

Both.  When you purchase your medications, the retail cost of your drug can move you from one part of your Medicare Part D plan coverage into another part. When this occurs and your prescripti . . .

Your Medicare Part D drug plan coverage is broken into four parts and you cross between these parts or phases of coverage based on the retail cost of your drugs or your total out-of-pocket spending.&n . . .

Yes, you are responsible for the co-payment of the purchase plus the amount of the purchase that exceeds your Medicare Part D plan's Initial Coverage Limit ($4,430 in 2022). However, in such a sit . . .

The Donut Hole Discount applies to the portion of a formulary drug's retail cost that carries over from the Initial Coverage phase and into the Coverage Gap.

In most cases, you must pay your Medicare Part D plan's Initial Deductible before you receive Medicare Part D coverage - just as you would with other types of insurance, such as automobile insurance. . . .

No.  In this situation, you will pay your initial co-payment (or cost sharing) for the $1,894 drug plus the difference of the retail amount that takes you into your plan's Donut Hole or Coverage . . .

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” . . .

When the cost of your medication covers two parts of your Medicare Part D plan, you have a “straddle claim” where your drug costs are split over two different phases of your drug plan cove . . .