Understanding Coverage Stages
Summary
Medicare prescription drug coverage progresses through different stages during the year. As you and your plan spend money on covered medications, you move through these stages, and the amount you pay may change.
Not every member will move through every stage, and the specific costs associated with each stage vary by plan.
Your plan’s Prescription Drug Coverage page contains the deductible, copays, coinsurance, and out-of-pocket amounts that apply to your coverage.
Why Coverage Stages Matter
Coverage stages help determine how much you pay for covered prescription drugs throughout the year.
As your prescription drug spending increases, your coverage may change and your share of the cost may be different depending on the stage you are in.
Understanding how these stages work can help you better plan for prescription drug expenses.
Coverage Stages
| Coverage Stage | Description |
|---|---|
| Deductible Stage | The first stage, during which you pay the full cost of covered prescription drugs until your plan's deductible is met. If your plan has a $0 deductible, you start in the next stage. |
| Initial Coverage Stage | Once the deductible is met, your plan pays its share of the costs, and you pay any applicable copay or coinsurance. Most members remain in this stage for most of the year. |
| Catastrophic Coverage Stage | This stage begins after you reach a specific out-of-pocket threshold. For the rest of the year, covered medications are generally available at no cost to you. |
Extra Help and Coverage Stages
If you qualify for Extra Help (Low-Income Subsidy), some coverage stage rules may work differently for you.
Many members who receive Extra Help have lower prescription drug costs throughout the year and may pay reduced copays or no deductible.
Insulin Cost Cap
Covered insulin products are subject to federal cost-sharing protections.
Even if you have not met your deductible, you will not pay more than the Medicare-established maximum amount for a one-month supply of a covered insulin product.
Check your plan’s Prescription Drug Coverage page for additional details.
Looking for Your Actual Drug Costs?
Coverage stages explain how prescription drug coverage works throughout the year, but the amounts that apply to you depend on your specific plan.
View your plan’s Prescription Drug Coverage page
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