Questions About Your Pharmacy Coverage? We’ve Got You Covered

How Much You Pay Depends on Your Stage

Your prescription drug coverage is broken down into four stages, which are set by the Centers for Medicare and Medicaid Services (CMS). How much you pay for a prescription depends on each coverage stage. As you move through different stages, your prescription drug plan costs may change throughout the year.

Stage 1: Yearly Deductible

You pay the full cost of your medicines until you reach your prescription drug deductible amount. Your deductible is how much you pay out of pocket for covered medicines before your coverage kicks in. If your plan has no deductible, you’ll start in Stage 2.

Stage 2: Initial Coverage

Your plan pays for part of each prescription medicine you buy. You pay a copay (a set amount) or coinsurance (a percent of the cost) for your share of the medicine. How much you pay depends on:

• Your plan
• Your medicine’s tier
• The pharmacy you use

Check your Evidence of Coverage for your copay and coinsurance information. This stage ends when the amount spent by you and your plan adds up $4,660 in 2023. This limit is set by Medicare.

Stage 3: Coverage Gap or “Donut Hole”

You’ll pay 25 percent of the cost for brand-name and generic drugs because there’s a temporary limit on how much your plan can pay. For 2023, you’d stay in this stage until your total out-of-pocket costs on covered medicines reach $7,400. This amount is also set by Medicare.

Stage 4: Catastrophic Coverage

This coverage is meant to protect you from financial disaster in case of a serious medical emergency. You enter this stage of your coverage is when your total annual prescription costs exceed the $7,400 limit set by Medicare in 2023.

Once you reach $7,400 in total out-of-pocket costs in 2023, you’ll pay a copay ($4.15 for generic and $10.35 for brand-name) or a 5 percent coinsurance, whichever is more. Your plan and the government will pay for the rest, until December 31. At the start of the new benefit year, you’ll return to Stage 1.

How Do I Know Which Stage I’m In?

Your monthly Explanation of Benefits (EOB) tells you which stage you’re in and how much you’re spending on prescriptions. Keep track of this amount so you know if you’re close to the coverage gap. Your EOB will be mailed to you each month. It’s also online when you sign in to your Braven Health member account.

Have a Prescription to Fill?

As a Braven Health member, you have access to more than 66,000 in-network retail pharmacies, plus mail order for 90-day supplies of most maintenance medicines. Read more about how to fill a prescription, and see which drugs are covered under your plan.