If I have not yet met my initial deductible and must fill a $1500 prescription, will any of the $1500 be applied to the my coverage [initial coverage phase], or will I have to pay the whole $1500 before my coverage goes in to effect?

Straddle Claims · updated Feb 3, 2025

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