The amount you pay before a plan covers your prescription drug costs.  

During this stage, the plan pays its share of the cost and you pay your share.  You are in this stage until your payments and the plan’s payments total $4,130 for the year.

When your drug costs and plan payment for the year reach $4,130, you enter the Coverage Gap Stage (donut hole).  You will pay 25% of the cost for formulary brand-name and generic drugs.  You will stay in this stage until your out-of-pocket costs for the year reach $6,550.

After your out-of-pocket costs for prescription drugs reach $6,550, the plan will pay most of your drug costs for the rest of the year.  You will pay either 5% of the cost of the drug, or a co-pay of $3.70 for generic drugs or $9.20 for all other drugs.

Tier

Preferred Retail Rx 30-day supply

Standard Retail Rx 30-day supply

Preferred Mail Order 90-day supply

Tier 1: Preferred Generic

$0

$14

$0

Tier 2: Non-Preferred Generic

$7

$22

$0

Tier 3: Preferred Brand

$47

$54

$125

Tier 4: Non-Preferred Brand

38% coinsurance

43% coinsurance

$35%

Tier 5: Specialty

33% coinsurance

33% coinsurance

N/A

Initial Enrollment Period (IEP)

7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65

Annual Enrollment Period

October 15 – December 7 (effective for Jan 1)

Special Enrollment Period

Special circumstances (ie losing employer coverage)