Straddle Claim for purchase of $700 medication while in the 2013 Intial Coverage Phase

Question: I use a medication that is called Welchol and a 3-month supply is around $705.96. Right now, I have $151.17 before I enter the Coverage Gap and I wanted to know what I should pay the next time I re-order my medication. Usually, my Medicare prescription drug plan pays $597.96 and I pay $108 for my portion.

Your next purchase of Welchol will be a straddle-claim (a purchase that falls into two phases of your Medicare Part D plan).

In this case, the purchase will be covered in both the Initial Coverage Phase and the Coverage Gap.

The first portion of the retail purchase price ($151.17) will count toward the 2013 Initial Coverage Limit of $2,970 and you probably will pay $108 for this portion of the purchase - based on your plan's cost-sharing.

Next, assuming the medication is a brand-name drug, you will receive the 2013 Donut Hole discount of 52.5% (you pay 47.5% of retail) on the remaining amount that falls into the Coverage Gap.

The remaining retail price in the Donut Hole is calculated as: $705.96 (retail price) - $151.17 (what you pay before reaching the Initial Coverage Limit) = $554.79

So you will pay the discounted amount of 47.5% of the remaining retail price or (0.475 * $554.79) = about $263.52

The total cost for this medication purchase will be around: $108 + $263.52 = $371.52.

Naturally, this is an estimate and your costs may vary.

Here is an example of the retail price history of this medication on this site