When performing a plan comparison, you may notice that the patient is in the deductible phase for the entire year even though their total out-of-pocket cost is higher than the deductible limit. Read on to learn two common reasons why this happens!
The monthly drug premium does not count towards the deductible.
The monthly premium amount is included in the total out-of-pocket cost, but it does not count towards the deductible. This could explain why the total out-of-pocket cost is higher than the deductible limit, yet the patient remains in the deductible the whole year. Here's an example:
The deductible for the Express Scripts Medicare - Choice plan is $350. The total out-of-pocket cost (circled in red) is higher than this limit -- $1,115.28, but the patient remains in the deductible the whole year...
Click on a month to see a breakdown of the monthly costs. You'll see that the patient is only taking one medication. The cost of this drug counts towards the $350 deductible, but the monthly premium of $87.10 (circled in red) does not, which is why they remain in the deductible the entire year.
Some drug tiers are excluded from the deductible and do not count towards the deductible limit.
Several plans cover certain drug tiers immediately, before the patient reaches their deductible limit. This means that these drugs will be covered as if the patient is in the initial coverage phase, even though the patient is technically in the deductible, and the copays for these drugs will NOT count towards the deductible limit.
This situation happens often and can easily be identified by comparing the patient's copays and full costs for each medication. If the patient is paying the tier copay or coinsurance for a drug, even though the patient is still in the deductible phase, that medication is excluded from the deductible and will not be counted towards the deductible limit. Here's an example:
You can see that the patient is paying a low tier copay for the medications circled in red (Diclofenac and Fluoxetine), even though the patient is in the deductible phase. Because of this, we can conclude that the Express Scripts Medicare - Choice plan excludes these drugs from the deductible and their costs will not count towards the deductible limit.
You can also see drugs excluded from the deductible (point this out to your patients) on the plan comparison print out under the "Drug Coverage and Restrictions" section. When a drug is excluded from the deductible, the deductible copay will match the "tier copay" for that drug. Here is an example:
Always examine the breakdown in costs to identify and explain these nuances to your patients!
Did the drug costs change for a patient even though they haven't transitioned into a different phase of coverage? Click here to find out the answers to your question!