Straddle Claim example of going from your Initial Coverage Phase into the 2013 Donut Hole
Straddle Claims and high costs · published Aug 29, 2013
Not exactly. If you are only $92 away from exceeding your Initial Coverage Limit of $2,970 (before reaching your Donut Hole or Coverage Gap) and your next prescription has a retail cost of $351, then a portion of the purchase costs will fall within your Medicare Part D plan's Initial Coverage Phase and a portion of the purchase will fall within your 2013 Coverage Gap - where you will receive a 52.5% discount on name-brand drugs (you pay 47.5%).
You will have what is called a "straddle claim" or a purchase that will “straddle” two portions of your Medicare Part D plan at one time. The actual calculation will depend on your plan’s co-payment or cost-sharing amount that you pay for the medication, but no matter what, you will never pay more than the $351 retail price.
As an example, if your plan’s co-payment is $30 for the $351 medication, you will pay the $30 on the $92 portion of the purchase that falls in the Initial Coverage Phase and the remaining portion $259 ($351- $92) will fall into your Coverage Gap or Donut Hole. In the Donut Hole, you will receive a 52.5% discount on the $259 or pay $123.03 – or ($259 * 47.5%).
Using the example $30 co-payment, the total cost for the $351 name-brand medication should then be around $153.03 ($30 + $123.03).
Naturally, the actual costs will vary depending on your plan’s cost-sharing (co-payment or co-insurance).
Here is a link to another example of a straddle claim calculation on this site
Read more in our Frequently Asked Questions section on Straddle Claims.