With January coming to a close, many of you have probably been to the pharmacy and realized that there is a prescription deductible on your plan they you may not be accustomed to having in the past. Keep in mind, if the plan you are on has a deductible, you will pay the retail cost of the prescription until it is met and then co-pays begin. If these costs are too much, there is another option. The government created a payment plan, that is not a savings program. Please see the Medicare Prescription Payment Plan (M3P) Blog for more details.
HELPFUL NOTE: These figures only apply to prescriptions that are found in the formulary for the Medicare Advantage or Prescription Drug Plan you are on. If the prescription is not covered, you will pay the retail cost of that prescription until the end of the Plan Year.
For a quick 2025 recap:
Maximum out of Pocket on Prescriptions:$2,000
Plan Deductibles: $0 - $590 ($590 is the federally mandated maximum)
Deductibles count towards: Tiers 3 - 5, some plans Tiers 4-5
Visual Examples below:
For my example, I am using myself as a client of a major insurance provider:
I have a prescription deductible of $495 on this specific plan. I will pay the retail cost of my prescriptions on my first pick up. Once I pay up to $495, I then pay only co-pays.
In the images below, it shows my retail cost of the prescriptions, and the co-pays. The second image is going to be a rough estimate of my monthly costs of my prescriptions. For example; Restasis’ retail cost is $436.65, when I go to pick up my prescriptions I am going to pay roughly $493.41 (see last image for visual)
Once that deductible is paid off, that is when the prices you are most familiar with will start appearing.
HELPFUL NOTE: Medical deductibles and copays do not go towards your $2000 maximum. The only payments that go towards the $2000 cap are prescription deductibles, copays and coinsurance.