The deductible stage marks the first payment stage of your health insurance benefit. Understanding how your deductible works will help you anticipate healthcare costs and avoid surprises at the pharmacy counter.

 

What is a Deductible?

A deductible is the initial out-of-pocket amount you are responsible for when receiving covered prescriptions. Deductible amounts vary by plan.

 

How Deductibles Work in Prescription Drug Coverage

At the start of the plan year, you may pay the full cost of certain prescriptions until your deductible is met.

Once you reach your deductible, your plan begins covering a portion of your prescription costs. This is often referred to as a copay or coinsurance.

 

Not all medications apply to the deductible. Some preventive or maintenance drugs may be covered right away, depending on your plan.

 

Meet Sarah (example member): For Illustrative purposes only.
Sarah’s pharmacy plan has a $300 deductible.

• In January: Sarah fills a prescription that costs $120. She pays the full $120 because she hasn’t met her deductible yet.
  → Deductible remaining: $180
• In February: Sarah fills another prescription that costs $200. She pays $180 to finish meeting her deductible. After that, her plan begins helping her pay.
  → Deductible met: ☑
• March and beyond: Sarah now only pays her normal copay or coinsurance for covered prescriptions for the remainder of the plan year. 

Review your Member ID card under “Prescription Drugs” to find your copay or coinsurance cost breakdown. For example it may read, “Deductible then $10/$30/$50” etc.

 

Our Role

Pharmacy Benefit Dimensions’ Member Servicing team or your medical provider can provide you with your deductible balance at any time. If you have any additional questions about your benefits or coverage, our team is always available to help you navigate your plan with clarity and confidence.

Connect

You can learn more about your pharmacy benefit and explore helpful resources anytime at pbdrx.com/members. As always, if you have specific questions about your coverage, Pharmacy Benefit Dimensions Member Services Department is available Monday through Friday from 8 a.m. to 11 p.m. ET. at (716) 635-7880 or 1-888-878-9172 (TTY/TDD users can call 711).