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Where can I see my Medicare plan's cost-sharing information?

Category: Cost-sharing: What You Pay
Updated: Nov, 01 2023


Your Medicare plan must tell you what you will pay for cost-sharing and cost-sharing information can be found in your plan's Summary of Benefits document (that you receive when enrolling in a Medicare plan) or the Annual Notice of Change letter (ANOC) or Explanation of Benefits document that you will receive every year from your existing Medicare plan (or you can download from the plan's website).

You can also find basic cost-sharing information on your Medicare plan's marketing information or the plan's website or you can call your plan's Member Services department (using the toll-free number found on your Member ID card) to learn more about the plan's cost sharing.

"Cost-Sharing", as defined by the Centers for Medicare and Medicaid (CMS), is the portion of the total healthcare or prescription drug cost that you pay yourself.  Cost-sharing can include copayments ($10 for a doctor visit), coinsurance (25% of retail for a Tier 4 drug), and/or deductibles ($480 you pay before drug coverage begins).

Your Medicare plan's cost-sharing can vary depending on whether you are in-network - or out-of-network (for Medicare Advantage plans) or whether you are using a standard or preferred network pharmacy (for Medicare drug plans).


Cost-sharing can be further defined as:

Copayments or the fixed cost you pay for healthcare or prescription drug coverage.  For example, you pay $40 for each visit to your Primary Care Physician (PCP) or $10 for a Tier 1 generic drug.

Coinsurance or the fixed percentage of the total cost that you will pay of the drug or healthcare coverage.   For example, you may 25% of the retail price for any Tier 3 brand-name medications - so if the retail price is $100, you will pay $25 coinsurance.  (Important):  As the retail prices of your formulary medications change throughout the plan year, your cost-sharing or coinsurance can also change.

And your deductible is the amount of money you pay toward your healthcare or drug cost before your Medicare plan begins to provide some coverage.  Sometimes you will hear people saying that you are responsible for 100% of the healthcare or drug cost until you spend a certain amount of money - and then you "share" the cost with your Medicare plan.  For example, if your Medicare Part D plan has a $480 deductible, you will pay the first $480 of any drug purchases before you and your Medicare plan begin to "share" the cost of drugs (either through copayment or coinsurance).

As an example, in your Medicare plan documents you may see cost-sharing information such as:


Benefits
In-Network Out-of-Network
 Doctor Visits - Specialist
 $25  $40
 Emergency Care (worldwide)
 $75  $75
 Diagnostic Tests and Radiology Services
 20% of costs
 30% of costs



Cost-Sharing Information on Q1Medicare.com

We have the cost-sharing details for all Medicare prescription drug plans online and they can be viewed in our Q1Medicare® Medicare Part D Plan Finder (PDP-Finder.com/FL) and Medicare Advantage Plan Finder (MA-Finder.com/44319).  You can see the example below for the formulary drug cost-sharing for different formulary tiers (for example, you pay $1 for a prescription of a Tier 1 "Preferred Generic" when filled at a preferred network pharmacy).

Examples of cost sharing chart

We also provide a portion of the healthcare cost-sharing information for Medicare Advantage plans (when available) in our Medicare Advantage Plan Finder.  For more information, you can telephone the Medicare plan for a complete and up-to-list of all cost-sharing information.

Example of Medicare Advantage plan cost-sharing

(original source: Medicare.gov [with our additional information])





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